Inspection on 07/11/05 for New Hope Project

This inspection was carried out on 7th November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

New Hope Project 25/10/06

New Hope Project 07/06/05

New Hope Project 27/09/04

New Hope Project 25/05/04

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

CARE HOME ADULTS 18-65 New Hope Project 377-381 Queens Road New Cross London SE14 5HD Lead Inspector Kate Matson Unannounced Inspection 7th November 2005 10:45 New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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 New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service New Hope Project Address 377-381 Queens Road New Cross London SE14 5HD 0207 6356339 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) Penrose Housing Association Mrs Omolara Oluyomi Amusan Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: New Hope Project is registered for 12 men who are mentally disordered offenders leaving regional medium secure units. The service is offered in partnership with South London and Maudsley Mental Health Trust under the supervision of a Community Forensic Consultant. Service users are expected to work with the psychiatric services throughout their stay at the Project. The project is managed by Penrose Housing. The property is owned and maintained by Hyde Housing Association. It is located in New Cross Gate, close to local shops, community facilities and public transport. The home has been converted from three houses and provides service users with en-suite bedroom accommodation on the first floor. The house is set back from the main road and there is a garden at the rear of the property. One of the twelve places is kept for overnight trial visits by prospective service users. A planned rehabilitation programme is offered to assist service users to move on to suitable alternative accommodation where less support will be provided. Individual and group work in the home aims at developing service users skills and abilities. Service users are supported to attend day centres, adult education and training, leisure and recreational activities. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced statutory inspection was carried out over 7.5 hours. The inspection included discussion with three service users, the deputy manager and another staff member, examination of service users files, staff records and other records. What the service does well: What has improved since the last inspection? What they could do better: New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 6 The assessment of need of service users should be available on file to evidence that assessment and so that progress of service users can be monitored. Although the wishes of service users with regard to illness and death had started to be discussed as part of the assessment and care planning process, this needs to be a fuller discussion in order to be able to plan for these eventualities. Photographs and evidence of the physical and mental fitness of staff must be included in the recruitment procedure. Times of fire drills need to be recorded in order to ensure that they take place at different times. Also although water temperatures are tested and adjusted if too hot, there was sometimes a delay and the provider must ensure that water is delivered close to 43 C unless a risk assessment of service users abilities indicates this is not necessary. 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. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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 New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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): 2 The needs of service users are fully assessed before they are offered a place at the home; however, it is recommended that these assessments are available on service users’ files in order to assess progress. EVIDENCE: The personal files of four service users were examined. Three of these files included evidence of assessments completed prior to them being offered a place and commencing periods of trial leave at the home. One service user was still on trial leave from hospital and it was noted that only an initial assessment was on file and this did not clearly indicate that the project was able to meet the needs of the service user. The deputy manager and another staff member confirmed that another assessment had taken place and that the assessment had confirmed that the project was able to meet the service users needs but this assessment had not yet been typed up. It is recommended that all assessments are available on service users files in order to assess progress. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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): 6, 7 and 9 The project has a comprehensive care planning system in place. Service users are encouraged to make their own decisions as far as possible. Risks to service users and others are assessed and managed. EVIDENCE: The personal files of four service users were examined. Two of these included care plans that covered all aspects of daily living skills, personal and health care support as well as social aspects of the person’s lifestyle but highlighted needs agreed with the individual. These were regularly reviewed and the service users signed the document to indicate their agreement. There was also evidence of regular psychiatric clinics held at the home and recorded sessions with the service users key worker. The two service users who had most recently moved did not yet have a full care plan in place but assessments of areas of need had been completed and the deputy manager stated that full care plans would normally take six weeks to complete. All of the service users spoken to confirmed that they made their own decisions within restrictions imposed by the mental health act in some cases. All but one of the service users manage their own money and all shop and cook for themselves with support where needed. The organisation employs an New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 10 advocate to support service users in a community meeting though this post has recently been made vacant. One service user represents the views of the others, at a forum involving other projects in the group. All of the files examined included risk assessments included at the referral stage and further developed within the care planning process. The care plans identify risks, and include management and contingency plans for if a service user should relapse. These are regularly reviewed with care plans. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 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): 12, 13, 15, 16 and 17 Service users take part in appropriate educational and occupational activities and utilise the local community. Service users have appropriate relationships. Routines at the home promote independence and respect service users’ rights. Service users are supported to prepare healthy meals. EVIDENCE: The home has a resident’s employment scheme where service users apply for jobs advertised in the home. Jobs available include two housekeeping posts and one gardener. The service users are paid above the minimum wage and can work for five hours per week. The organisation employs an Education Training and Employment Coordinator who assists service users to find appropriate education, training or employment within the community. One service user does voluntary work three days per week. Service users are currently taking part in a number of courses at local colleges including cookery, music, advocacy, carpentry, literacy, football and computing. A social skills course is also being run at the home by an ex service user. Service users confirmed that they utilise the local community. All have access to free travel. The project has links with a local scheme that supports people New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 12 with mental health problems to access the local community. Service users use local leisure centres regularly as well as cinema and museums and places of worship. Activities are decided at service user meetings and currently a trip to Paris is being planned. Service users confirmed that they are able to have visitors and that they were aware of the visiting policy. Service users decide how far they wish family members to be involved in their care. The deputy manager stated that one service user who had lost touch with family members is being supported to trace them. Service users confirmed that they have keys to their rooms and the front door. Individual rooms also have an intercom telephone. Staff do not enter a person’s bedroom without first speaking to them over the phone and then knocking before entering. Rules on smoking, alcohol and drugs are clearly stated in the service users contract. Service users’ mail is given to them unopened. Service users shop and prepare meals for themselves as part of the rehabilitation process. Support is given where necessary and this is determined in care plans. There are food hygiene notices in the kitchens to ensure service users prepare and cook food safely. There are weekly health and safety checks on cupboards and fridges that also serve to determine the nutritional value of food eaten. Daily observation of individuals also allows staff to ensure that service users have a balanced, varied and nutritious diet. Service users are weighed if their care plan indicates it is necessary. A house meal is prepared monthly as a social activity. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 13 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): 21 The project has begun to address the issues associated with illness and death but fuller discussion with service users is required. EVIDENCE: Although the home is not a home for life, previous inspections had required that service users wishes with regard to illness and death be recorded in their care plans. At this inspection the deputy manager stated that this issue was now part of the assessment and care planning process. Of the four files examined only one had information around this issue and this was their wishes regarding burial or cremation. However a fuller discussion needs to take place including, the service users wishes if they were to become ill, who they would want to be informed, where would they want to be if they were ill, who would be responsible for arranging a funeral etc. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 14 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): Neither of these two outcomes was assessed. At the last inspection, the following judgement was made in respect of these outcomes:- There are systems in place to ensure that service users’ views are listened to and acted upon. The home’s policies and procedures ensure that service users are protected from abuse. EVIDENCE: New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 15 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): 28 Shared spaces complement and supplement service users’ bedrooms, including the provision of smoking and no smoking areas. EVIDENCE: There are two kitchens and two laundries for the use of service users and these are domestic in style. There is a communal dining area that allows individuals to eat communally or in groups. Service users have access to an adequate sized garden at the rear of the property. There are three other communal rooms in the home. One lounge has Sky television for service users use. Another has a music system, a computer and library books and is known as the music or quiet lounge. The third room is available for private consultations. At the last inspection it was noted that smoking is permitted in both of the lounges, meaning that any non-smoking service users are unable to watch television or listen to music in a smoke free environment, unless in their own room. The provider was required to ensure that there is at least one no smoking communal area available for service users. At this inspection the deputy manager stated that in consultation with service users the quiet lounge had been made a no smoking room. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 16 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): 34, 35 and 36 The home’s recruitment practices protect service users though physical and mental fitness of staff must be also evidenced as part of the process. The home’s training programme ensures that the needs of service users are met. Staff are well supported and supervised. EVIDENCE: At the last inspection it was found that some records were not available at the home and a staff member had commenced work before the receipt of a new disclosure from the criminal records bureau and a check against the list of people considered unsuitable to work with vulnerable adults. This was of concern because it places service users at risk of potential abuse. At this inspection the deputy manager confirmed that records were now kept at the home and that staff did not commence employment until all of the appropriate checks had been received. The staff files of four staff members were examined and all included evidence of the appropriate checks. However it was noted that evidence of interview was not available on two staff files though the deputy manager confirmed that these had taken place. This information must be on the staff file to evidence that a thorough recruitment procedure is in place and that it is in accordance with equal opportunities. Also photographs and evidence that the person is physically and mentally fit for the job were not available. The provider must ensure that this information is available to ensure that service users are supported by staff who are fit to provide care to them as well as being required by regulation. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 17 At the last inspection it was noted that although all staff have an individual training and development profile, to assess training needs on an individual basis there did not appear to be a training plan for the home as a whole. This was required to ensure that training is based on the needs of staff and service users. At this inspection a training plan was available in addition to a record of the training that had been so far completed. The deputy manager stated that all staff had either completed or were completing relevant NVQ qualifications to ensure that staff are skilled to deliver care that meets the needs of service users. This will be examined further at the next inspection. The deputy manager had formulated an induction programme based on standards set by the previous sector skills council (TOPSS). Although this is acceptable, it is recommended that the induction be based on the new sector skills council (Skills for Care) standards to ensure that staff training is as up to date as possible. The manager provides supervision to the two deputies who supervise the rest of the staff team. Staff files examined indicated that a supervision contract is in place and staff receive regular supervision and appraisal of their performance to ensure that they are effective and supported to carry out their work. In addition staff meetings are held every two weeks and team building exercises take place every month. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 18 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): 39 and 42 The home has good quality assurance systems in place to ensure that service users’ views underpin self-monitoring, review and development of the home. The health, safety and welfare of service users are promoted and protected though closer attention to recording of fire drills and testing of water temperature is required. EVIDENCE: The home has many good systems in place to ensure that a quality service is delivered. These include: a residents’ representative who is paid to attend a monthly tenants forum and a monthly management meeting, an advocacy worker paid to represent service users’ views (although this post had recently been made vacant), regular review of policies and procedures, and a team review day. The organisation also completes annual service user satisfaction surveys; however, at the last inspection it was noted this did not include the views of relatives or other stakeholders and was not specific to New Hope. In order for the project to effectively review the quality of it’s service, the project was required to conduct its own satisfaction survey and include the views of relatives, visiting professionals and other stakeholders as well as those of New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 19 service users. At this inspection it was found that this had been done and some surveys were examined. The deputy manager confirmed that when a greater response was received the results would be summarised and made available to all those who took part. Project goals had also been developed to reflect aims and outcomes for service users in accordance with a previous recommendation. Reports of the provider’s monthly, unannounced visits to the home were also now being sent to CSCI as required to evidence that the provider monitors the quality of the service. The home has safe working practices in operation to ensure the health, safety and welfare of service users. Records showed that fire, gas and electrical systems in the home are regularly checked, serviced and inspected. Certificates of electrical safety were now available for portable electrical appliances as required by previous inspections. Also the deputy manager confirmed that all staff assisting service users with food preparation now had food hygiene certificates and an example of one was seen. It was noted that fire call point tests were not being checked weekly, but this had been picked up by the deputy manager and was being addressed. Fire drills were being held regularly though the time of the drill was not being recorded. This must be addressed to evidence that drills take place at different times. The home has an annual water test and hot water temperatures are tested weekly, and adjusted where necessary, however there was sometimes a delay in this happening. The provider must ensure that water temperatures are delivered close to 43 C unless risk assessments indicate that service users are able to check water temperatures for themselves. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 20 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 X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X 2 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 New Hope Project Score X X X 2 Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 X DS0000025652.V264177.R01.S.doc Version 5.0 Page 21 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 YA21 Regulation 15 Requirement The registered manager must ensure that service users wishes with regard to illness and death are recorded in their care plans. If they do not wish to discuss the issue this must be recorded (Previous timescale of 31/10/05 not met though progress has been made) The registered provider must ensure that all windows in service users accommodation are provided with curtains or blinds in order to protect their privacy (Previous timescale of 30/07/05 not met though progress had been made) The registered provider must ensure that staff records include a recent photograph and that the recruitment process includes obtaining evidence of the person’s physical and mental fitness. The registered provider must ensure that records of interviews are kept on staff files. The provider must ensure that water temperatures are delivered close to 43 C unless DS0000025652.V264177.R01.S.doc Timescale for action 31/03/06 2. YA27 16 (2) (c) 31/12/05 3. YA34 19 (1) (a) and (b) 31/03/06 4. 5. YA34 YA42 19 (1) (a) 13 (4) 31/03/06 31/12/05 New Hope Project Version 5.0 Page 22 6. YA42 23 (4) (e) risk assessments indicate that service users are able to check water temperatures for themselves The registered provider must ensure that the times of fire drills are recorded. 31/12/05 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 Refer to Standard YA2 YA35 Good Practice Recommendations It is recommended that all assessments are available on service users files in order to assess progress. It is recommended that the staff induction be based on the new sector skills council (Skills for Care) standards to ensure that staff training is as up to date as possible. New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark 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 New Hope Project DS0000025652.V264177.R01.S.doc Version 5.0 Page 24 - 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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