CARE HOME ADULTS 18-65
Old Registry (The) 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX Lead Inspector
Helen Fontaine Unannounced Inspection 19 September 2005 15:00 Old Registry (The) DS0000025931.V251158.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 Old Registry (The) DS0000025931.V251158.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. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Old Registry (The) Address 70 Aldborough Road South Seven Kings Ilford Essex IG3 8EX 020 8590 7076 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) Mr Alan John Philp Mrs Pamela Joan Philp Mr Robert Steer Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Moderate to high level of disability. Date of last inspection 23rd March 2005 Brief Description of the Service: The Old Registry is registered to accommodate 8 adults with learning disabilities. Service Users have high levels of dependency and limited communication and cognitive abilities. The home is operated by Alpam Homes, a private organisation, which operates three other registered care homes for people with learning disabilities in the London Boroughs of Redbridge and Newham. Alpam Homes also operate their own day care centre, for service users who live in their care homes. The home is situated in a residential area of Seven Kings, in the London Borough of Redbridge and is close to shops, places of worship, community facilities and transport routes to central Ilford, London and Essex. The house is in keeping with other properties in the area and does not set users apart from the local community. The house is well decorated, furnished and maintained. The premises are not fully accessible to wheelchair users, although there are bedrooms and a bathroom/shower room on the ground floor. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection took place in accordance with the annual inspection programme for this home. The previous inspection took place in January 2005 and was an unannounced inspection, where five requirements were identified. One of the five remains, the other four have been met but two additional Requirements were identified from this inspection. A tour of the home was undertaken, where a number of the Service Users were seen and communicated with. A number of documents were seen and a member of staff was spoken to. The Manager was present during the inspection; the home currently has two vacancies. What the service does well: What has improved since the last inspection? What they could do better:
The home does need to make sure that opened food containers in fridges and freezers are appropriately labelled with an expiry date. It was noted that the freezers are old and in a poor condition, but the Manager did point out that the home is in the process of buying new freezers. It was noted during the inspection that there was no toilet paper in the toilets, there was plenty in the staff toilet. There does need to be some arrangement for the Service Users to have access to this facility, taking into account their needs and risks of using it inappropriately. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 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. Old Registry (The) DS0000025931.V251158.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 Old Registry (The) DS0000025931.V251158.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): 1, 2 and 5 All prospective Service Users moving into the home are given a homes guide that is appropriately presented for people with Learning Disabilities. Each Service User has an in-depth assessment before moving into the home that establishes that the home can meet their needs. Each Service User has a written contract that they sign and terms and condition with the home. EVIDENCE: During the inspection documents looked at showed that each prospective Service User is given a homes guide that provides information. Service Users files were looked at and each file had an in-depth assessment carried out by the Manager that identified that the home could meet the needs of the Service Users. The file also had copies of the written contract that had the signature or mark of each Service User, along with the terms and condition of the home. Old Registry (The) DS0000025931.V251158.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, 8 and 9 The Service Users are informed of their assessed and changing needs, their personal goals are reflected in their care plan. All 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. EVIDENCE: During the inspection Service Users individual files were looked at and each Care plan and review had been signed or the Service Users had made their mark. The Care Plan was presented in a format that the Service Users with Learning Disabilities would be able to understand. During the inspection the Residents meetings minutes was looked at and the quality audit feed back, this identified that the Service Users are consulted on all aspects of life in the home. The documents looked at showed risk assessments for the Service Users and charts of activities that they take part in. These activities included all aspects of domestic chores in the home, which staff supported the Service Users to help with. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 16 Service Users are able to take part in age, peer and culturally appropriate activities. Service Users are and do take part in the local community. All Service Users rights are respected and responsibilities recognised in their daily lives. EVIDENCE: The Manager said that the all the Service Users attend a number of both daytime activities and evening activities that allow them to meet with their peers. The Manager and a member of staff spoken to said that the week before the inspection all the Service Users had been away on a holiday. The home does make sure that the Service Users are part of the local Community and go out to social events. It was observed during the tour of the building the respect that the staff showed to the Service Users and no bedrooms were entered without the permission of the Residents. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 11 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 and 20 Service Users physical and emotional health needs are met, no Service Users are able to control their own medication. EVIDENCE: During the inspection Service Users files were looked at and showed that all the Residents physical and health needs are met. It was also noted that the internal audit undertaken, where the views of the Service Users identified the emotional needs and some individual likes. The homes policies and procedures promote Service Users having control of their own medication, however none of the Residents of the home were able to. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 12 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 and 23 The Service Users views are listened to and acted on, the home have a robust policy and procedure to protect the Residents from abuse, neglect or selfharm. EVIDENCE: The Residents meeting minutes was looked at during the inspection and gives the Service Users the opportunity to complain. The member of staff spoken to said that the home cares well for the Service Users and any complaint or suspicion of any kind of abuse would be dealt with. Documents looked at showed that the home had a robust policy and procedure to deal with any incidents or abuse situation. The Manager of the home is clear after a discussion, which incidents needed to be reported to The Commission for Social Care Inspection. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 13 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 and 30 The Service Users live in a homely, comfortable and safe environment, the toilets and bathrooms provide sufficient privacy but no toilet paper. The home is clean and hygienic. However, service users’ welfare could be compromised by open containers in fridges not being appropriately labelled. EVIDENCE: During the inspection a tour of the home was made and it was seen to be very homely, comfortable and safe environment for the Service Users to live in. The toilets were looked at and offered the Service Users sufficient privacy, but none of the toilets had any toilet paper in them. The Manager said that the Service Users do have problems with using the toilet paper appropriately; the home does need to have an arrangement that gives Residents access to toilet paper. The home was seen to be clean and hygienic, this included the kitchen, bathroom and toilet areas. Open food containers were found in the fridge without appropriate labels. This must be addressed. Freezers were found to be old and in poor condition; the manager stated that the home was in the process of purchasing new ones. For this reason this has been put as a recommendation in this report, it will be required of the home if this has not been achieved at the home’s next inspection.
Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 14 Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 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): 34, 35 and 36 Service users are protected by the home’s recruitment procedures and Service Users’ needs are met by appropriately trained staff. All staff are supervised on a regular basis. EVIDENCE: During the inspection staff files were looked at and all staff had CRB’s and two references. It was also noted that all staff had an individual training and development assessment and profile. Staff supervision notes were also looked at and all staff were receiving regular supervision. Staff meeting minutes were looked at and a member of staff spoken to said that their views are always listened to. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 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 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 Service Users views underpin all self-monitoring review and development by the home. The home promote and protect the Service Users with their policies and procedures. EVIDENCE: The home now undertake a quality monitoring and quality assurance system, which was seen during the inspection. Each of the Service Users, with the support of staff have been able to give their views and carers and other professionals have also received the questionnaire. The Manager said that anything that was raised during this process would be looked at and resolved. The member of staff spoken to said, that the home looked after the Service Users very well. However, a requirement from the previous inspection is being repeated in this one, namely that the home must make available for inspection a business and financial plan. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 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 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X 2 X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Old Registry (The) Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 2 DS0000025931.V251158.R01.S.doc Version 5.0 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 2 3 Standard YA27 YA30 YA43 Regulation 16(2) 16(2) 25 Requirement The home must make sure that the Service Users have access to facilities in the toilet The home must make sure that all opened food containers are labelled with an expiry date. The registered persons are required to make available for inspection – a business and financial plan. This is a restated requirement. Timescale for action 19/11/05 19/11/05 19/11/05 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 Refer to Standard YA24 Good Practice Recommendations That all Freezers are replaced. Old Registry (The) DS0000025931.V251158.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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