Inspection on 10/05/05 for Mount Carmel

This inspection was carried out on 10th May 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Carmel 02/01/09

Mount Carmel 03/01/07

Mount Carmel 30/11/05

Mount Carmel 21/02/05

Mount Carmel 28/04/04

Similar services:

Rugby House Project

City Roads Crisis Intervention

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Hartley House

Brook Drive, 124

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

CARE HOME ADULTS 18-65 Mount Carmel 12 Aldrington Road London SW16 1TH Lead Inspector Louise Phillips Unannounced 10th May 2005 08:55hrs 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 Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Mount Carmel Address 12 Aldrington Road London SW16 1TH 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 8769 7674 020 8698 0412 Mount Carmel Hostel for Recovering Alcoholics Ltd. Ms Ruth Elizabeth Allonby Care home (PC) 18 present alcohol dependence (A) present drug dependence (D) present alcohol dependence over 65 present drug dependence over 65 (D(E)) Category(ies) of Past or registration, with number Past or of places Past or (A(E)) Past or Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may from time to time, admit up to 3 named persons over the age of 65 for short term rehabilitation. Date of last inspection 21st February 2005 Brief Description of the Service: Mount Carmel is a care home for service users who are recovering from alcohol addiction. The home provides treatment and therapy to service users who have followed a period of total abstinence. The stay at Mount Carmel is for approximately six months. During this time service users are supported to begin a Twelve Step programme of recovery from their addiction. The home focuses on the first five steps of the programme with support through group therapy and one-to-one counselling. The home is a four storey building and accommodates up to 18 men or women who each have their own bedroom. On the ground floor there is a kitchen, large communal dining area, two lounges, two counselling rooms and a small kitchenette for use by service users. There is a large parking area to the front of the property and a well-maintained garden to the rear of the home. The home is situated close to local shops and public transport links. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day for approximately 6 hours. A tour of the premises took place and staff and care records were inspected. On the day of the inspection six members of staff and four service users were spoken to. There was one vacancy at the home. What the service does well: What has improved since the last inspection? What they could do better: A significant number of Requirements remain outstanding from the previous inspection and it is vital that these are addressed as a matter of priority. These include addressing health and safety issues in relation to Control of Substances Hazardous to Health (COSHH) product assessments and also Legionella risk assessments being carried out. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 6 The home must also work to develop risk management plans for use following the assessment of risk of service users at the home. Training is required for all staff in relation to fire safety and abuse awareness to ensure the Protection of Vulnerable Adults. Food hygiene training is also needed for all those involved in food preparation including staff, service users and ex-service users. It was observed that a number of areas around the home require decorating, notably two bathrooms needing a complete re-furbishment, and a Requirement has been made to ensure this is carried out. Other areas that were identified as needing re-decoration were the hallways throughout the home and the main lounge area on the ground floor of the home. 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 Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.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 Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.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, 2, 3 and 5 The assessment process for prospective service users is good and fully involves the service user. EVIDENCE: The manager discussed that potential service users are referred to the home via the care manager or from the service user themselves. Following this they are sent a brochure detailing the aims and objectives of Mount Carmel, an application form for a place and a date to attend the home for an assessment. The manager stated that the current service users are involved in showing potential service users around the home and allowing the opportunity to discuss any queries about how they find the programme supports them. The home has a very clear service provision and the Service Users Guide which is titled ‘Residents Information Booklet’ details the specific expectations of service users who are offered a place at the home. Four service users files were examined. The assessment documentation in each file consists of the application form that has been completed by the service user and added to by the staff members involved in the assessment. The assessment provides sufficient information on the individuals’ history including their alcohol drinking behaviour, physical issues, family background and any psychiatric problems. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 9 Once service users move to the home they are provided with a Licence Agreement that states the terms and conditions of their stay. These were seen in each file and were signed by the individual service user. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 10 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, 8 and 9 The needs of the service users are well met however there is no standardised format in place for the collation of information about service users. No progress has been made to develop risk management plans to ensure the safety of service users. EVIDENCE: During the inspection four service users files were examined. Each file was found to contain care plans and a monthly summary of the service users progress. The deputy manager described that on the first Tuesday of each month each service user receives feedback on their progress from the other service users. This is used by the keyworker to compile a monthly summary of their progress through the stages of their treatment. These summaries were found to be varied in completion, with the most recent dated March 2005. The care plans did not reflect that the summaries had been used to update them. This was identified on two occasions where the summary was dated for March, yet the care plan last reviewed in January 2005. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 11 The files and recording format for each service user was varied with documentation collated in individual files and keyworkers’ folders. The service could benefit from a standardised format of compiling information about service users in one file. Each service user has a risk assessment in place that is of a ‘yes/no’ tick box design. The areas assessed for risk include dangerous behaviour regarding service users’ history, emotional and mental health problems, self-care, risk from others, physical problems and use of medication. The previous inspection required that fuller information regarding the control measures to reduce risk is detailed following the risk assessment. This Requirement has not been met as the current format identifies the risk but does not detail how this is monitored or managed. The deputy manager described how service users are encouraged to be fully involved in their care. The literature provided to service users about Mount Carmel emphasises their responsibilities in relation to fulfilling their programme and living within a therapeutic community. This information is in the format of the Residents Information Booklet, Service Manual and a leaflet describing the recovery programme. The information is provided prior to service users moving to the home to enable them to make an informed choice to apply for a place at the home or not. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 12 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, 12, 13, 14, 15, 16 and 17 The staff have a good understanding of the service users’ support needs. The aims of the home promote personal development for each service user. EVIDENCE: The service provided by Mount Carmel is specifically designed to support service users to develop, take on personal responsibility and lead an alcoholfree life. The home provides this support through group sessions and one-toone counselling therapy. The programme is structured from Monday-Friday with groups commencing at 9:00am through to 3:30/ 4:30pm. Group sessions include discussion about feelings, peer assessments, nutrition and drama. Throughout the inspection a number of groups were observed to be in progress and supported by staff or managed by the service users. The deputy manager discussed that for the first four weeks of their stay new service users are escorted by another service user any time they leave the premises. During this period contact with family and friends is limited to Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 13 telephone contact only. This is to enable service users to focus on their recovery at the initial stages of their programme. The service benefits from the input of a nutritionist who holds group sessions and carries out individual work with service users who need support to lead a more healthy life. The meals at the home are prepared by the current and ex-service users on a rota basis with the support of staff. The previous inspection required that staff and service users who prepare food undertake training in Food Hygiene. At the time this Requirement was still within the timescale. The manager stated that since the last inspection no staff or service user had received this training so this Requirement has been restated. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 14 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 and 19 The health needs of service users are well met. EVIDENCE: The manager discussed that service users attend to their own personal care needs. Support with physical health is provided by the local GP who all service users are registered with. The service benefits from the professional knowledge of two staff who are Registered Mental Health Nurses who can monitor the mental health needs of service users. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 15 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 The home has a satisfactory complaints policy with some evidence that service users feel that their views are listened to and acted upon, although there is no system for the recording of complaints. EVIDENCE: Mount Carmel has a clear complaints procedure that details how to make a complaint and how this will be managed. The Residents Information Booklet provides the contact details of the CSCI. The manager described that all service users are given a verbal explanation of the complaints procedure as part of their admission to the home. The manager discussed that throughout the year there is a quarterly management committee meeting. Prior to this meeting taking place members of the committee hold a ‘surgery’ to enable service users to raise any issues or areas of concern that can be taken to the meeting to be discussed and addressed. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 16 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 and 30 The standard of décor in the home is adequate in areas, however the hallway walls are stained and require re-decorating. Two bathrooms are in a poor state of décor and shabby in appearance. EVIDENCE: A tour of the building was carried out and the home was found to be adequately decorated and furnished in a number of areas. The hallways from the main front door leading up to the top floor were dull in appearance, walls noted to be stained in areas and chipped paintwork, with all the hall areas requiring re-decoration. A bathroom on the top floor and the female bathroom on the first floor are in a very poor state with dated furnishings and stained bath and sink areas. These areas are unhygienic as black mould was observed around the bath rim and on the tiles. The manager stated that the whole home is due for re-decoration and that this is anticipated to commence in the summer. The previous inspection recommended that these bathrooms be re-decorated. No progress has been made in these areas and it is required that the bathrooms identified are refurbished as a priority. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 17 The main lounge on the ground floor was observed to have an area beneath the window where some repair work had been started but not completed, with an area of plaster needing painting. It is recommended that this work be completed to make the lounge area more pleasant and homely. Bedroom 7 was observed to require the installation of a window restrictor. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 18 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, 32, 33, 34, 35 and 36 The information contained in the staff files is good and demonstrates that appropriate recruitment procedures are in use. EVIDENCE: Mount Carmel is staffed between 8:00am and 7:30pm Monday to Friday only. Out of these hours there is an on-call bleep system in place. At weekends the building is staffed from 10:00am to 6:00pm by counsellors who have their 1:1 meetings with service users. Four staff files were observed and found to contain appropriate recruitment documentation regarding references, Criminal Records Bureau checks, application form and identification information. All staff have a job description for their role and records are maintained of annual appraisals. All staff receive supervision on a monthly basis and the manager discussed that the handover period between shifts is also used to discuss any issues within the staff team. The previous inspection required that all staff receive first aid and fire safety training. At the time of this inspection this Requirement was still within the timescale and the manager showed information to demonstrate that first aid training is planned for early June 2005. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 19 The training records indicate that the staff do training relevant to their role, however no staff have undertaken training in the Protection of Vulnerable Adults or abuse awareness and a Requirement has been made to ensure that all staff receive this. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 20 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 and 42 The manager has a good understanding of the areas in which the home needs to improve. Some progress has been made to implement the health and safety Requirements of the previous inspection. EVIDENCE: The manager of Mount Carmel described a number of areas of improvement that are required to progress the service in relation to staff training and décor around the home. Discussion with the manager demonstrated that she has a good sound knowledge of her management responsibilities and the importance of balancing these with the needs of the service users. The manager does not hold a formal qualification in management and it is recommended that she undertake the NVQ level 4 in Management. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 21 Since the last inspection the home has worked to ensure that the Commission receives monthly reports in accordance with Regulation 26 of the Care Homes Regulations 2001. Further work is required on the information provided to the Commission to give a clear representation of the status of the home at the time of the visit. This must include discussion with service users, details of any complaints and any developments or plans for the future. The previous inspection identified a number of health and safety issues that were followed up at this inspection. The home has developed a system for carrying out weekly checks of the temperature of the hot water dispersed from the taps around the home. However, there is a Requirement that remains outstanding regarding risk assessments in relation to Control of Substances Hazardous to Health (COSHH) products that are in use at the home. A further Requirement regarding a Legionella risk assessment was still within the timescale at this inspection and this has been carried over following this inspection. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 22 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 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mount Carmel Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 23 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 YA9 Regulation 12(1) & 13(4) Requirement The Registered Persons must ensure that the risk assessment documentation fully outlines all identified risks of service users and the plans in place to manage these (Previous timescale of 01.05.05 not met) The Registered Persons must ensure that all persons involved in the preparation of food receive training in Food Hygiene. This is with regard to staff and service users (date of 01/07/05 within timescale at time of inspection, so restated on this occasion). A window restrictor must be installed on the windows of Bedroom 7. The Registered Persons must ensure that the bathroom on the top floor and the female bathroom on the first floor are refurbished and re-decorated. The Registered Persons must ensure that all care staff receive First Aid and annual Fire Safety training (date of 01/07/05 within timescale at time of inspection, so restated on this occasion). The Registered Persons must Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 24 Timescale for action 31/07/05 2. YA17 13(3) & 16(2)(j) 01/07/05 3. 4. YA24 YA27 & YA30 13(4) 13(3) & 23(2)(d) 30/06/05 31/08/05 5. YA35 18(1)(c), 23(4)(d) & 13(4) 01/07/05 13(6) 6. YA39 26 7. YA42 13(4) & 12(1) ensure that all staff employed at the home receive training in abuse awareness. The Registered Persons must ensure that the reports in accordance with Regulation 26 clearly address all issues as outlined within this Regulation. The Registered Persons must en sure that a full risk assessment is carried out with regard to COSHH. This must address safety issues with regard to the availability abd use of potentially hazrdous substances within the home (previous timescale of 01/05/05 not met). The Registered Persons must ensure that a risk assessment for Legionella is put in place for the home (date of 01/07/05 within timescale at time of inspection, so carried over on this occasion). 31/08/05 30/06/05 31/07/05 01/07/05 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. 3. Refer to Standard YA24 YA24 YA37 Good Practice Recommendations It is recommended that the repair work on the wall in the main lounge is completed and the area re-painted. The plans for the re-decoration of the home should be supplied to the Commission. The Registered Manager should plan to obtain the NVQ Level 4 quailification in Management. Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 Mount Carmel G54-G04 S10212 Mount Carmel V214640 100505 Stage 04.doc Version 1.30 Page 26 - 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. 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