Inspection on 09/06/05 for Mount Adon Park

This inspection was carried out on 9th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Mount Adon Park 04/08/06

Mount Adon Park 17/02/06

Mount Adon Park 24/01/05

Mount Adon Park 14/05/04

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

CARE HOME ADULTS 18-65 Mount Adon Park 49 Mount Adon Park Dulwich London SE22 0DS Lead Inspector Pam Cohen Unannounced 09 June 2005 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 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 Stationary 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. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mount Adon Park Address 49 Mount Adon Park, Dulwich, London, SE22 0DS Telephone number Fax number Email 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 8299 0305 020 8693 8675 Odyssey Care Solutions for Today Mr Satyanand Mungul CRH Care Home 4 Category(ies) of PC Care home only registration, with number of places Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2005 Brief Description of the Service: Mount Adon Park provides a home for four adults with learning disabilities. It is run by Odyssey-Care solutions for today, a private provider who also have other homes in the area It is a three-story building that is indistinguishable from the othe buildings in a residential road near Forest Hill. The home is close to shops and transport links but is situated in an extremely hilly street which would cause difficulties for anyone with mobility problems. There are gardens front and back and on-street parking. Each service user has a single room and there are communal kitchen, living and dining areas. At the time of inspection there was one vacancy. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two visits. On the first visit the inspector toured the premises, inspected records including individual service user files and health and safety documentation. She spoke to staff, a service user who was in the home and also spoke to the relative of a service user on the phone. She returned two days later to speak to the manager to get information that staff had not been able to give. What the service does well: What has improved since the last inspection? What they could do better: There needs to be an up-to-date Statement of Purpose and admissions policy. The complaints policy and procedures which should be in place to make sure Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 6 that service users’ concerns are heard and acted upon, needs improving. The whistle blowing policy also needs to be available for staff. A quality assurance system which is another way of hearing the views of interested parties also needs to be put in place, together with accessible and up-to-date policies and procedures. Oddysey need to take account of staff morale to ensure that they feel that they are heard and valued in the new organisation. They also need to ensure that staff have job descriptions and training targeted to their needs. 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. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 standard(s) 1,4,5. The home is not yet providing up-to-date information for prospective service users. EVIDENCE: The manager told the inspector that the home does not yet have an up-to-date statement of purpose, service users’ guide or admissions policy; these have now been outstanding for over a year. They are especially important as there is a vacancy and a potential person who may be coming to the home. However terms and conditions which also needed updating have been completed. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 standard(s) 6,7,10 Good individual planning means that service users’ needs can be met and their wishes respected wherever possible. Keeping files in an open cupboard means that there is a risk to their right to confidentialiy. EVIDENCE: The format of individual plans seen, was good and full information was available about service users’ needs. Reviews, where the plans are updated, are held with service users and their advocates or relatives. Where a decision has been made by those other than the service user, this has been recorded with a full explanation. The home has now registered under the Data Protection Act but service users’ files were being kept in an open cupboard in a room used by all. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 10 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 standard(s) 11,13,14,15,16,17 Individualised programmes mean that service users have good opportunities to take part in the social and developmental activities which they enjoy. Staff also give excellent support to enable service users to take charge of their own food provision. EVIDENCE: Weekly activity charts and care plans show that each service user has an individualised programme of social and learning activities. One service user showed the inspector work he had done at college; this reflected his love of acting and daily records showed that staff had arranged for him to go to an audition for a part. Family visits were seen to be an important part of the individual programmes. A relative of a service user was concerned however that of late, staff time has not been available to accompany service users to make trips out. From reading care plans, the inspector saw no evidence that service users’ sexuality was being considered and the manager confirmed this. The inspector saw documentary evidence and heard in discussion with staff that service users’ rights are respected. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 11 The inspector was told how each service user works out a menu with their key worker and then goes shopping to buy what is needed. One of the service users was going shopping on the day of inspection. Service users cook their meals and eat them individually but have group meals twice a week. Staff are on hand to advise on healthy eating and to help with cooking. A family member said that the weekly allowance for food had gone down, and was concerned that the quality of food purchased, should not deteriorate. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 standard(s) 18,19,20 The home looks after the health and personal care needs of its service users well. EVIDENCE: Staff have a good knowledge of how to best give service users the care they need. Records showed that professionals, such as Occupational Therapists, had also been consulted where appropriate. A service user said that if he needed help, staff were good at this. Records show that service users’ health is well looked after, with good liaison with health professionals and this was confirmed by a relative of one of the service users. The CSCI’s pharmacy inspector carried out the last inspection and at this inspection evidence was seen, that her requirements and recommendations had been carried out. However, medication was being kept in a fridge that service users have access to. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 standard(s) 22,23 The complaints process is not satisfactory. There is no policy available and no evidence of consistent recording of a service user’s complaints. EVIDENCE: The home does not have an accessible complaints policy for its service users and their relatives, although the manager did have a general policy for Odyssey care solutions. The inspector also saw that complaints from a service user were not recorded and investigated. The manager was not able to find a copy of the home’s whistle blowing policy which protects staff if they wish to bring issues they wish to bring attention to issues they may be worried about. Other aspects of protecting vulnerable adults are in place with proper policies and evidence of staff training. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28.30 The home is generally well maintained and provides a good environment for the people who live there. EVIDENCE: The home is bright, homely and suitable for the people who live there. One service user showed the inspector his room which he said he liked. It was large and furnished as he wanted it. A room which is empty will not be decorated until the person who will be moving in can choose the decorations he wants. Communal areas have diminished as a large games area in the basement has been taken over by the managing organisation but there is still ample communal space. The only shortcoming was that the carpet in the lounge is in a poor condition and needs either an extremely good clean or replacement. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35,36 Experienced staff work in sufficient numbers with good supervision, ensuring that service users are well supported. Targeted staff training is not happening so skills are not being enhanced. Staff morale in relation to the new registered provider is low and this has the potential to affect service users adversely. EVIDENCE: Odyssey has taken over as registered provider about a year ago. Staff job titles have changed but they have not received new job descriptions. This means they cannot at the moment be sure of their, or others, roles. Staffing levels and staff experience are such as to ensure that service users’ needs met and preferred lifestyles can be maintained. Although there are training courses for staff to attend a training and development plan had not been updated since 2002/3. A member of staff said that he was feeling de-skilled as there had been no training appropriate for his needs in the past year. The staff reported that they had regular supervision, as well as annual appraisals from the manager, and were well supported by him in their role. However there were also concerns expressed about the new registered providers, staff saying that they cannot be sure that the organisation as a whole take notice of what staff or service users have to say about the service. This is influencing staff morale. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40 The manager is able to ensure that the home is run in the best interests of the service users. However up-to-date policies, procedures and systems for quality monitoring are not yet in place. EVIDENCE: The manager is a registered nurse, with experience of working with people with learning disabilities. He is finishing his NVQ4 Management award. Staff who spoke to the inspector said that he was supportive and managed in an open way and their contributions were valued. There is not yet a formalised quality assurance programme or annual development plan in place. Policies and procedures are still being updated which is being done centrally with no input from staff. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 17 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x 2 3 Standard No 22 23 ENVIRONMENT Score 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 x 3 3 2 3 3 Standard No 31 32 33 34 35 36 Score 2 x 3 x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mount Adon Park Score 3 3 2 2 Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 x x x G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 18 YES 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. Standard 1 Regulation 4(2) 5(2) Requirement The registered person must ensure that an up-to-date service users guide and statement of purpose are produced and a copy sent to the CSCI . Previous time scale of 31st August 2004 not met. The registered person must ensure an up-to-date admissions policy is produced and a copy sent to the CSCI Previous time scale of 31st August 2004 not met. The registered person must ensure that services users files are kept securely. The registered person must ensure that service users sexuality is considered as part of their care planning. The registered person must ensure that medications that need refridgeration are stored securely. The registered person must ensure that there is a complaints policy for the home and that all complaints are recorded, and investigated. The registered person must Timescale for action 31st October 2005 2. 2 4 Sch 1 31st October 2005 3. 4. 10 15 17(1&6) 12(3) 31st August 2005 30th September 2005 31st August 2005 31st August 2005 31st August Page 19 5. 20 13(2) 6. 21 22 7. 23 21 Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 8. 9. 10. 24 31 35 23(2d) 17(2) Sch 4(6e) 18(1ci) 11. 39 24 12. 40 4 Sch 4 12(3) ensure that there is a whistle blowing policy accessible to staff. The registered person must ensure that the lounge carpet is cleaned or replaced. The registered person must ensure that staff have job descriptions for their posts. The registered person must ensure that there is an up-todate training and development plan for staff. The registered person must ensure that there is a quality monitoring system and annual development plan. The registered person must ensure that policies and procedures are updated with input from stakeholders. 2005 30th September 2005 30th September 2005 31st October 2005 31st March 2006 31st March 2006 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 13 Good Practice Recommendations The registered person should ensure that there are sufficient staff to accompany service users out when needed. Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Southwark Area Office Ground Floor, 46 Loman Street London SE1 0EH 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 Mount Adon Park G52-G02 S60229 Mount Adon Pk V231156 Stage 4.doc Version 1.30 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!