Inspection on 07/03/06 for Mitcham Lane

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mitcham Lane 20/06/07

Mitcham Lane 18/08/06

Mitcham Lane 10/08/05

Mitcham Lane 16/02/05

Mitcham Lane 15/07/04

Mitcham Lane 16/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mitcham Lane 229 Mitcham Lane London SW16 6PY Lead Inspector Davina McLaverty Unannounced Inspection 7th March 2006 10:00 Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mitcham Lane Address 229 Mitcham Lane London SW16 6PY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8677 3336 020 8971 0060 Mr Clifford Steven Oakley Mr Abdelkrim Damousi Max Thembinkosi Mbangcolo Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Staffing levels are reviewed to meet the assessed needs of current and prospective service users and that waking night care is provided. No clients are to cook without supervision from staff. Date of last inspection 10th August 2005 Brief Description of the Service: 229 Mitcham Lane is situated in a residential area in Streatham, close to local bus routes. The home provides personal care for clients who have mental health needs. All clients are male and are supported by male members of staff. Each client has their own room with adequate communal facilities. The home is domestic in character and provides a homely atmosphere. There is a level garden area, accessed via patio doors from the dining area. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over one day starting at 10.30 am and finishing at 2.00pm. The inspector met two of the three residents, the acting manager, the provider and a support staff member. A number of records were examined, which included a resident care plan, health and safety records, staff and residents meetings minutes and staff recruitment records. A tour of the communal areas took place. What the service does well: What has improved since the last inspection? What they could do better: Staff records must include all the information detailed in Schedule 2 of the Care Home Regulations. The manager’s application to be the Registered Manager must be submitted to the Commission. Risk assessments must be updated to ensure residents current needs have been addressed. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 3 & 4 The home has an appropriate Statement of Purpose and Service User Guide in place. Care needs are identified during the assessment process, prior to the resident being admitted to the home. EVIDENCE: The Statement of Purpose and Service User Guide had been updated and contained relevant information regarding the service offered. Details of the Regulatory Authority had been included as required at the previous inspection. The manager was aware of the homes assessment procedure for assessing a new resident. The manager also stated that the assessment would include several visits to the home to ensure that the prospective residents needs could be met, as well as allowing the prospective resident the opportunity to see the premises, meet the other residents and make an informed choice as to whether they wanted to live there. Views of involved relatives/carers would be considered if it is the prospective residents wish. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 67&9 The needs of the residents are identified and planned with involvement of the individual and their key worker. Residents are encouraged by staff to participate in the life of the home and to acquire new skills to enhance their lives. Risk assessments are carried out but must be regularly reviewed and updated as necessary. EVIDENCE: One care plan was examined and seen to be satisfactorily maintained and reviewed in consultation with and signed by the resident, as well as the key worker. The care plan seen, focussed on particular areas of need for the individual e.g. personal hygiene, activities, communication. The manager reported that since coming to the house, care plans had been rewritten to better identify the needs of the residents and the whole evaluation process. The manager discussed various ideas he wanted to put in place to engage residents more with their care plans. A risk assessment was seen and covered appropriate areas, although staff must ensure that risk assessments like the care plans are regularly reviewed Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 10 and updated as the one seen was dated 2004. A requirement was made to address this. Residents are encouraged to make their own decisions as to how they wish to live their lives. Support is given as required e.g. budgeting. Residents meetings are now taking place and staff encourage all residents to participate in the running of their home. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Resident’s rights are respected with residents being encouraged and supported with various responsibilities of daily living. EVIDENCE: At the time of the inspection two of the residents were seen in the home. Both people were relaxed and very much at home. One resident said that he did not like to go out and enjoyed watching television. The resident confirmed that staff would knock on his bedroom door and wait to be asked in. The other resident goes out daily to the local shops. Staff were seen to be interacting appropriately with residents. Mail is given directly to the resident and support provided, if need be, in reading and responding to official letters. Staff reported that residents are all encouraged and supported to participate in household tasks e.g. hoovering, washing up and keeping the communal areas clean. Residents have individual responsibilities for their bedrooms. Rules on smoking, alcohol and drugs are addressed in the Statement of Purpose and Service User Guide, which all residents receive a copy of. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Residents receive appropriate levels of support to ensure their physical health and emotional needs are met. EVIDENCE: A record is maintained of resident’s health needs and of any appointments with GP’s, dentist, opticians etc. Residents are all registered at a local GP surgery and all three residents receive regular visits from their CPN as well as their social worker. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 A complaints procedure is in place with clear systems for the recording and monitoring of complaints. EVIDENCE: The home or the Commission had not received any complaints since the previous inspection. Details of the procedure, is in the residents guide. Both of the resident spoken with stated that they were happy living at the home and had no complaints. They were both aware of the complaints procedure. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 28 & 30 The premises are homely and the communal areas seen were in a good state of repair and decoration. The home was seen to be clean and tidy on the day of the inspection. EVIDENCE: The premises are in keeping with the local community and have a style and ambience that reflects the home’s purpose. The premises are safe and comfortable with close access to local amenities. All the communal areas of the home was found to be satisfactory. A large lounge (with television) is available with appropriate furnishings and adequate seating. A large kitchen/dining room is available which leads out into the garden area. Appropriate appliances were seen in the kitchen. There are adequate bathing and toilet facilities for residents’ use, which are situated near to resident’s rooms. On the day of the inspection the home was found to be clean and hygienic. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 Records relating to staff were not all in place. Staff training in respect of core training courses must be monitored and updated. Supervision of staff was found to be taking place regularly. EVIDENCE: Residents continue to be supported by an appropriate numbers of staff. The manager stated that following a waking night staff do not work the early shift. Two staff are currently undertaking the NVQ Level 2 in Care course and one person is due to start their NVQ Level 3. Details of core training e.g. food hygiene, Health and Safety, first aid and medication was not currently on files examined, a requirement was made to address this issue. Examination of two staff files identified that not all the required checks detailed in Schedule 2 of the Care Homes Regulation were in place. Health declarations confirming that the staff member was physically and mentally fit for the purposes of work were not on the files. The proprietor stated that they had been carried out and showed the inspector a copy of the form used. However, as they could not be located during the inspection new forms must be completed. A requirement was made to address this issue. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 16 Formal supervision of staff has started and records of two staff were seen. The Registered Persons must ensure that a minimal of 6 sessions takes place each year. Minutes of monthly team meetings were seen. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 A new manager is in post who has a good understanding of the residents needs. Health and Safety systems are in place to ensure the safety and welfare of the residents. EVIDENCE: The manager started work in the home in October 2005 and has almost completed his probation period. An application to be registered, as the manager must be submitted to the Commission. The manager stated that he was about to commence his Managers award training. Health and Safety systems are in place. A number of records were seen and found to be in order. These included the fire alarm system, which is tested weekly, fire drills, which are carried out quarterly, and the servicing of the fire extinguishes and fire blanket. Fridge and freezer temperatures are taken daily and again records seen were satisfactory. Appropriate documentation was seen for the fixed electrical installation, gas safety certificate and portable appliance Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 18 testing which is now due. The proprietor stated that this was in hand as the home had a contract with the provider. Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 3 X X X X 3 X Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA9 YA34 Regulation 13(4) 19(1) Sch 2 Requirement Timescale for action 30/04/06 3 YA35 18(1) 4 YA37 9(1) The Registered Persons must make sure that risk assessments are regularly reviewed. The Registered Persons must 30/04/06 ensure that evidence is available in the home which evidence that staff are mentally and physically fit for the posts they are in. The Registered Persons must 30/05/06 ensure that each staff has a current training plan, which evidences core-training courses. The Registered Person must 30/04/06 ensure that application is submitted to the Commission for approval of the current manager. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Mitcham Lane DS0000010210.V285359.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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