Inspection on 22/08/05 for Oval Road (170)

This inspection was carried out on 22nd August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Oval Road (170) 30/11/06

Oval Road (170) 18/01/06

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 OHara Unannounced 22 August 2005 09:30 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. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Oval Road (170) Address 170 Oval Road East Croydon Surrey CR0 6BN 020 8686 9814 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) Mrs Mercidita Bheecarry Mr Mike Bheecarry Mrs Mercidita Bheecarry Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 24/01/05 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) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards. This unannounced inspection started at 9.30am and finished at 10.50am on a Monday morning. Methods of inspection included previous inspection experience of the home, a tour of the premises observation of contact between staff and service users, discussion with service users and staff. The registered provider Mrs. Bheecarry supported the inspection process and the previous requirements and recommendations were discussed. Records examined included, service user finances, service user occupational therapist assessments and complaints. Criminal Records Bureau Checks, staffing records, training records and health and safety certificates were examined as part of the inspection at the registered managers other care home at 170 Oval Road. What the service does well: What has improved since the last inspection? What they could do better: Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 6 In general the home appears to be well run and well managed. The management approach of the home creates an open, positive and inclusive atmosphere. All requirements and recommendations set at the last inspection have been met. As a result of this inspection there are four requirements. Although the home has developed a training programme, fire safety training has not been arranged therefore service users and staff could be placed at risk unless all staff has training on fire safety. The home has never had a visit from the Fire Authority in relation to fire safety in the home. The registered provider should contact the Local Fire Authority and arrange for a fire officer to visit both 170 and 164a Oval road. The registered manager should acquire a copy the Occupational Therapists assessment regarding the service users bathing needs and keep this on file. The registered provider should contact the bank for advice on opening a bank account for one of service users. The inspector would like to thank the service users, staff, the registered provider and her husband 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) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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) 2 and 5. In the main the home provides prospective service users and their representatives with good information they need to make an informed decision about whether or not to use the service. The admission procedure is adequate to ensure a thorough assessment of prospective service users needs and aspirations are carried out before they move in. EVIDENCE: The homes admissions procedure indicates that any new/prospective service user would have a full care manager’s needs assessment prior to moving into the home and includes reference to visits and to a four-week trial period. The registered provider said that she would follow these procedures if and when any prospective service user is identified. Service users have contracts that include all details a required to meet this standard; the service user and the registered provider signed these. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8. Service users are offered opportunities to contribute to the running of the home. EVIDENCE: There was evidence of regular joint monthly meetings for the service users from both 170 and 164a Oval Road. Minutes of these meetings included details of items for discussion, staff and service users in attendance, what was discussed, what were the service users opinions or concerns and actions to be taken and by whom. Service users have been involved in the homes recruitment procedures including deciding what questions to ask at interviews, sitting on the interview panel and employing members of staff to work with them in the home. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. Provision is made so that all service users attend appropriate social activities and become part of the local community. EVIDENCE: None of the service users at the home have a job. One service user attends Heavers Farm Daycentre five days a week another service user was getting ready to attend a luncheon club that she attends three days a week. The third service user was attending a temporary day centre set up at the registered providers other home at 164a Oval Road to meet the therapeutic needs of the service users at the 170 and the service users who live at 164a. There is a list of activities that service users do during the week, the list included painting and colouring, knitting, sewing, Bingo, dominoes and cooking. There is a TV, video and stereo in the living room for the service users use. Service users also have access to a computer. Two service users spoken to on the day of the inspection said that they are able to attend activities in the local community such as the Monday Club, The Octopus Club, Church, shows at Fairfields Hall in Croydon, shopping, restaurants and all service users have regular day trips and holidays. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 11 One service user said she had just come back from a weekend away with the day service, she said she went to Yorkshire and visited Emmerdale Farm. The registered provider said that all service users went to Sherburne Dorset on a four-day holiday in April this year and there are plans for day trips to Eastbourne and Littlehampton over the next two weeks. The registered provider said that one service user from each home will be going to Euro Disney in October this year. One service user does not have a passport so the registered provider is liaising with the service users relatives so that she can obtain one so she can go abroad on holiday. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 21. Overall the arrangements for health care needs of the service users are good and they receive personal support in the way they prefer. EVIDENCE: Service users are registered with a local General Practitioner. None of the service users have specialist medical conditions however the registered provider said that should the needs of the service users change then she would seek support and training to enable staff to support the service user. Service users have regular medical appointments. The home employs a Service User Medical Appointment recording system. The wishes of the service users upon illness and death have been sought and this information is recorded in the service user files. One service user is eighty-two years old. An Assessment was carried out by an Occupational Therapist as to the suitability of the bathroom in the home. A letter from Croydon Council stated that the service user had had an assessment carried out by the OT in February 2005 but was unable to apply for a disabled facilities grant to fund works that may be suggested to improve the service users daily living. The registered provider said that the OT informed her by phone that the home is meeting the service users bathing needs. The OT has not sent a copy of her assessment to the home. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 13 The registered provider must acquire a copy the Occupational Therapists assessment regarding the service users bathing needs and keep this on file. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 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: Complaints are logged into a complaints book. Information on how to complain is presented in written form and for current service users this is appropriate. The registered provider said that there have been no complaints made to the home in the last twelve months. The home has a copy of Croydon Councils Protection of Vulnerable Adult Policy. One member of staff recently attended Croydon Councils training for the Protection of Vulnerable Adults. Other members of staff are due to attend. The registered provider said that she was advised by a care manager and advocate of one of the service users to open a bank account in her own name for a service user who has difficulties with communication. The registered provider has opened an account and showed bank statements and receipts as evidence that she is operating the account for the benefit of the service user however Regulation 20 (1) of the National Minimum Standards states that the registered person shall not pay money belonging to ant service user into a bank account unless the account is in the name of the service user to which the money belongs. The registered provider must contact the bank for advice on opening a bank account for the service user in the service users own name. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 standard(s) 24 and 30. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic however the practice of wedging doors open in the home raises concerns about the safety of the service users in the event of a fire. EVIDENCE: During a tour of the home it was observed that hallway, kitchen and living room doors were wedged open. The registered provider said that she has never had a visit from the Fire Authority in relation to running her two care homes at 170 and 164a Oval Road. The registered provider must contact the Local Fire Authority for advice on the homes practices regarding fire safety in the home. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 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, 34 and 35. The homes procedures for staff recruitment has improved and now appear provide the necessary safeguards to ensure that so far as possible service users are not placed at risk of harm or abuse. Both service users and staff could be placed at risk unless all staff has training on fire safety. EVIDENCE: The registered provider and her husband support service users at the home. A part-time member of staff works at the home some mornings, evenings and on Saturdays. Staff attend regular monthly team meetings as required at the last inspection and staff meeting minutes examined recorded details of items discussed, staff in attendance, staffs opinions or concerns and actions to be taken and by whom. The registered provider has obtained Criminal Records Bureau Checks for all members of staff employed in the home. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 17 Staff files included the information as required in schedule 2 of the National Minimum Standards. The home is part of the Croydon Learning Partnership Committee. This is a group of providers who get together to plan training for their staff. There was evidence that the registered provider has developed a training programme for staff to attend mandatory training topics such as Moving and Handling, Health and Safety, Food Hygiene and First Aid as required at the last inspection however there were no plans for staff to attend Fire Safety training. The registered provider must ensure that all staff and managers working in the home attend Fire safety training. One member of staff said that she is completing an NVQ level 3 in care. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 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, 40 and 43. In general the home 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 is currently completing the Registered Manager Award NVQ level 4 qualifications. The home has a full set of policies and procedures. These documents fully comply with the required standards as defined in appendix 2 of the National Minimum Standards. Clear and proper indexing and filing of this guidance is in place and enables ease of reference for staff. The home has a certificate of liability insurance and a Landlords Gas Safety Certificate 21/06/05, Electrical Wiring and Portable Appliance Testing Certificates 06/05/05 were seen. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 19 Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 3 x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oval Road (170) Score 2 3 x 3 Standard No 37 38 39 40 41 42 43 Score 3 x x 3 x x 3 G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 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 18. Regulation 14(2). Requirement The registered manager must acquire a copy the Occupational Therapists assessment regarding the service users bathing needs and keep this on file. The registered provider must contact the bank for advice on opening a bank account for the service user in the service users own name. The registered provider must contact the Local Fire Authority for advice on the homes practices regarding fire safety in the home. The registered manager must ensure that all staff and managers working in the home attend Fire safety training. Timescale for action 30/11/05 2. 23. 20(1)a. 30/11/05 3. 24. 23(4). 30/09/05 4. 35. 23(4)d. 30/09/05 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. Oval Road (170) G53-G53 S28159 OvalRoad170 unann V196239 220805 Stage 0.doc Version 1.40 Page 22 Refer to Standard Good Practice Recommendations 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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