Inspection on 18/01/06 for Oval Road (170)

This inspection was carried out on 18th January 2006.

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

Other inspections for this house

Oval Road (170) 30/11/06

Oval Road (170) 22/08/05

Oval Road (170) 24/01/05

Oval Road (170) 05/07/04

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

CARE HOME ADULTS 18-65 Oval Road (170) 170 Oval Road East Croydon Surrey CR0 6BN Lead Inspector James O`Hara Unannounced Inspection 18th January 2006 11:00 Oval Road (170) DS0000028159.V271641.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 Oval Road (170) DS0000028159.V271641.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. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oval Road (170) Address 170 Oval Road East Croydon Surrey CR0 6BN 020 8686 9814 020 8686 9814 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) Mrs Mercidita Bheecarry Mr Mike Bheecarry Mrs Mercedita Bheecarry Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user over the age of 65 to be accommodated on condition that the home reviews the service user at least every six months, or sooner if the service user`s care needs notably change. The home must also renew the risk assessment on every occasion that there is a review and sooner if the need arises. 22nd August 2005 Date of last inspection Brief Description of the Service: 170 Oval Road is a terraced house located in a side street a few minutes walk from East Croydon Station. It is a small care home registered to support three adults with learning disabilities. Bus and tram services also serve the local area. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection at the home this inspection year. The inspection took place on a Wednesday morning/afternoon. Methods of inspection included a tour of the premises observation of contact between staff and service users and discussion with some of the service users. Records examined included staffing records, training records, health and safety and fire records, care plans, risk assessments and correspondence in relation to service users health issues. Previous requirements were discussed with the registered provider. What the service does well: What has improved since the last inspection? What they could do better: As a result of this inspection four requirements have been set. These requirements relate mainly to the home admitting a service user outside the category for which the home is registered and not carrying out proper assessments prior to admission. The home was also handed an immediate requirement notice not to admit service users outside the category for which it is registered. The registered providers took immediate action to comply with this requirement notice. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 6 Apart from the registered providers failure to ensure that the home only admits service users to the home for the category it is registered to it appears to be well run and well managed. The registered provider should also make arrangements for service users to have their care plans reviewed by their care managers and work towards service users having Person Centred Plans. As with the registered providers other home the home could now work towards improving the quality monitoring systems employed in the home and supporting the staff team to achieve NVQ level 3. The inspector would like to thank the service users, staff and the registered provider’s for their support on the day of the inspection. 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. Oval Road (170) DS0000028159.V271641.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 Oval Road (170) DS0000028159.V271641.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 registered provider failed to ensure that a prospective new service users needs were assessed prior to moving into the home. The home is registered to support people with learning disabilities the registered provider has breached National Minimum Standards regulations and moved a service user into the home outside of the homes registration category. EVIDENCE: One service user has moved out of the home as the her care manager felt that her needs would be better met at an older peoples service. During the inspection the registered provider stated that a new service user had moved into the home on a emergency trial period. The registered provider stated that the service users care manager said that the service user has mental health needs. As the home is registered to support people with learning disabilities the registered provider has breached National Minimum Standards regulations and moved the service user into the home outside of the homes registration category. The registered provider also failed to carry out an assessment of the service users needs or obtain detailed information on the service users needs from the service users care manager. The registered provider must carry out an assessment of any new service users needs prior to admission to the home. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 9 The registered provider must ensure that any new service user has their needs assessed by their care manager prior to admission to the home this assessment must be available in the home for inspection. An immediate requirement notice was handed to the registered provider that the registered provider must not admit any service user to the home outside the category for which the home is registered. The registered providers took immediate action to comply with the requirement notice. On the day of the inspection the registered provider contacted the mental health unit to advise them that the home is registered to support service users with learning disabilities and not mental health and advised them to arrange an alternative placement for the service user. The registered provider requested and was provided with an application to vary the homes certificate of registration so that she may admit service users with both mental health and learning disabilities. The registered provider hopes that the application to the Commission to vary the homes registration category will be successful and the home will be able to admit service users with mental health. The registered provider runs another care home just a few doors away. This home is registered to support service users with mental health. The registered provider and her husband are experianced in working with service users with both mental health and learning disabilities. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 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 the following standard(s): 6 and 9. Standards 7 and 8 were assessed as met at the last inspection. Arrangements must be improved to ensure all care plans are reviewed at least every six months and updated accordingly to reflect service users changing needs and aspirations. EVIDENCE: One service users file was examined. The service user last had her care plan reviewed in October 2004. The registered provider stated that she has tried to arrange a care plan review with the service users care manager. When the reviews are completed she plans to introduce the Person Centred Plan approach in the home. The registered provider stated that the service users risk assessments are reviewed at the care plan reviews. The registered provider must arrange for all service users to have their care plans reviewed by their care managers and that service users have a Person Centred Plan. Oval Road (170) DS0000028159.V271641.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): 15, 16 and 17. Standards 12, 13 and 14 were assessed as met at the last inspection. Appropriate arrangements are made so that all service users have regular contact with their friends and families. Service users are offered well-balanced nutritional meals based on their own personal preferences. EVIDENCE: The home encourages service users to keep in regular contact with their families and friends. The registered provider stated that relatives generally visit the home at Christmas and birthdays and that service users maintain contact with letters and telephone. None of the service users require a special diet. The registered provider stated that on Saturday evenings service users plan what they wish to eat for the rest of the week. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 12 Menus are drawn up and shopping is purchased however the registered provider said that sometimes the service users change their minds and request something that is not on the menu. In this case the registered provider records what service users have instead. Service users spoken to on the day of the inspection were confident and comfortable and spoke in a positive manner about the support they receive in the home. Oval Road (170) DS0000028159.V271641.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): 18 and 20. Standards 18, 19 and 21 were assessed as met at the last inspection. Overall the arrangements for health care needs of the service users are good and they receive personal support in the way they prefer. EVIDENCE: A requirement was set at the last inspection that the registered manager must acquire a copy the Occupational Therapists assessment regarding the service users bathing needs and keep this on file. This service user has moved out of the home so this requirement no longer applies. One service user has moved out of the home as the her care manager felt that her needs would be better met at an older peoples service. A variation to the homes registration that the home could accommodate a named service user over the age of 65 has been removed. Medication is stored in a locked cupboard in the kitchen. Medication administration and recording sheets were up to date and accurate. The home also has an appropriate system for recording the receipt and returns of medication. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 14 Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23. Complaints are handled objectively and the service users are confident that any concerns they may have are listened to and acted upon. The home has suitable vulnerable adult protection and abuse prevention measures in place to ensure the service users are so far as reasonable practicable protected from abuse, neglect and/or harm. EVIDENCE: The registered provider stated that there had been no complaints received by the home since the last inspection. A requirement was set at the last inspection that the registered provider contacts the bank for advice on opening a bank account for the service user in the service users own name. A bank account has been opened for the service user and a bank account statement was produced for December 2005. The registered provider stated that the service user must go to the bank with her in order to withdraw monies. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 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 the following standard(s): 24. Standard 30 was assessed as met at the last inspection. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. EVIDENCE: A requirement was set at the last inspection that the registered provider must contact the Local Fire Authority for advice on the homes practices regarding fire safety in the home. A fire officer from the London Fire & Emergency Planning Authority visited the home on the 16th of September 2005 and wrote to the Commission For Social Care Inspection stating that the arrangements for fire safety in the home are satisfactory. An extention has been added to the property so that the registered provider can offer day services to the service users. This has been agreed and assessed with Croydon Social Services and the home also offers day services to a small number of service users from other homes. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 17 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): 35. Standards 31, 32 and 34 were assessed as met at the last inspection. Improvements have been made to ensure that staff is appropriately trained to meet the needs of the service users. EVIDENCE: A requirement was set at the last inspection that the registered manager ensures that all staff and managers working in the home attend Fire safety training. Staff has acquired Fire safety training in the form of video training from BVS Video Training, after watching the video staff must complete and examination form and return this to the company if the student successfully completes the exam then a certificate is provided. The registered provider stated that four staff had completed the training but only one certificate has been returned the home at present. Staff has also attended training on first aid 20/12/05, food hygiene 07/12/05 and moving and handling 16/01/06. Oval Road (170) DS0000028159.V271641.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. Standards 37, 40 and 43 were assessed as met at the last inspection. Apart from the registered providers failure to ensure that the home only admits service users to the home for the category that the home is registered it appears to be well run and well managed. The management approach of the home creates an open, positive and inclusive atmosphere. EVIDENCE: The registered provider provided evidence of quality monitoring systems employed in the home. The registered provider stated that she is reviewing the homes performance for 2005 and this information will be recorded on her system. It was agreed that this system would be examined in detail at the next inspection. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 19 The registered provider produced recorded evidence of service user meetings for the 10/12/05, 05/11/05, 11/10/05 and the 29/07/05. The registered provider also produced one completed service user questionnaire however this was not dated. The registered provider produced a current certificate of liability insurance, Landlords Gas Safety Certificate 21/06/05 and a Portable Appliance Testing Certificate 06/05/05. The home does not have a water tank, a combination boiler supplies water from the mains system to the home and there is no need for a Legionella testing certificate. Oval Road (170) DS0000028159.V271641.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 1 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oval Road (170) Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000028159.V271641.R01.S.doc Version 5.0 Page 21 NO. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 16 (1) d. Requirement Timescale for action 18/01/06 2. YA2 14 (1) a. 3. YA2 14 (1) c. 4. YA6 14 (2) a & 15 (1). The registered provider must not admit any service user to the home outside the category for which the home is registered The registered provider must 18/01/06 ensure that any new service user has their needs assessed by their care manager prior to admission to the home; this assessment must be available in the home for inspection. The registered provider must 18/01/06 carry out the homes own assessment of any new service users needs prior to admission to the home. The registered provider must 31/03/06 arrange for all service users to have their care plans reviewed by their care managers and that service users have a Person Centred Plan. Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Oval Road (170) DS0000028159.V271641.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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