Inspection on 30/11/06 for Oval Road (170)

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oval Road (170) 18/01/06

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 Key Unannounced Inspection 30th November 2006 10:00 Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 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.V322107.R01.S.doc Version 5.2 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.V322107.R01.S.doc Version 5.2 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.V322107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow service users with a dual diagnosis of learning disability and mental disorder to be admitted. 18th January 2006 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.V322107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced site visit was carried out between 10.00am and 12 pm on a Thursday morning. Methods of inspection included a tour of the premises and discussion with the registered providers Mr and Mrs Bheecarry. Records examined included service users care plans, risk assessments, complaints, adult protection, staffing training and personnel records, medication, and health and safety records. Requirements and recommendations from the previous inspection were also discussed with Mr and Mrs Bheecarry. What the service does well: What has improved since the last inspection? The full time member of staff has completed an NVQ level 3 in care and is now completing NVQ level 4 the Registered Managers Award. Mrs Bheecarry stated that the two part time members of staff are attending NVQ 3 courses. The staff team have had relevant training enabling them to meet the needs of the service users living at the home. The service is now registered with the Commission to admit service users with a dual diagnosis of learning disability and mental disorder. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 6 What they could do better: 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. The summary of this inspection report can be made available in other formats on request. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 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.V322107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides prospective service users and their representatives with all the information they need to make an informed decision about whether or not to use the service. No new service user has moved to the home since the last inspection however all the procedures are in place should they be needed. EVIDENCE: The homes Statement of Purpose and Service Users Guide have recently been updated and include all of the information as required in the Care Homes Regulations. It was noted that the registered provider qualifications were included in the Service Users Guide and not the Statement of Purpose. Mrs Bheecarry was advised to keep the documents together. Mrs Bheecarry stated that one of the service users has been given a copy of the Service Users Guide; the other service user is unable to understand the contents of the document so this has been passed on to her relative for comment. It was reported during the last inspection that a service user with mental health had moved into the home on an emergency trial period. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 9 The home was registered to support people with learning disabilities. Mrs Bheecarry contacted the mental health unit to advise them that the home was registered only to support service users with learning disabilities and an alternative placement for the service was arranged. Mrs Bheecarry requested and was provided with an application to vary the homes certificate of registration so that the service could admit service users with both mental health and learning disabilities. The Commission agreed the application and a variation was granted to allow the service to admit service users with a dual diagnosis of learning disability and mental disorder. The home is registered to support three service users, there are currently two service users living at the home. Mrs Bheecarry stated that one service user recently moved from the home after a five-month stay. She stated that the service user, his care manager and the home agreed that the placement was not suited to the service users needs. The service user has moved back to his family home pending a new placement. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have care plans with detailed information on their needs and personal goals. Service users placement is kept under review by their placing authority. Service users have individual risk assessments and risk management strategies in place so that service users can participate in activities in the home and in the community in a safe manner. EVIDENCE: The home supports currently two service users with learning disabilities/mental health. One service users file was examined. The file included a personal planning book that is a work in progress and had been completed by the service user with support from staff. The file also included notes for a care plan review meeting on 7th February 2006, attended by the service user, the service users care manager and the registered providers. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 11 The registered provider stated that she had contacted the service users care manager by telephone requesting a copy of the care plan to keep on the service users file but had not yet received it. It is recommended that the registered provider write to the service users care manager requesting a copy of the care plan to keep on the service users file. The file also included current risk assessments, the risk assessments were kept under review. One risk assessment indicated that the service user had a history of making false accusations/allegations against staff and others. Mrs Bheecarry stated that this has reduced since she moved into the home however there were no guidelines for the registered providers or staff to follow should the service user make any allegations against staff or other service users. It is recommended that the registered provider contacts the service users care manager to consider/develop guidelines for the home to follow in the event of the service user making accusations/allegations against staff or other service users. Service users have meetings once a month. During an inspection at 164a Oval Road in October 2006 (Mrs Bheecarry other care home) Mrs Bheecarry produced minutes of service user meeting for April, May, June, Jul and August 2006, service users discussed house issues, what food they like to eat and holidays. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Provision is made so that service users attend appropriate social activities and become part of the local community. EVIDENCE: Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 13 None of the service users are employed. One service user attends Heavers Farm Daycentre five days a week the other service user was out with a member of staff on the day of the inspection. This service user attends college at Caterham on Fridays and the homes own day service on Tuesdays and Wednesdays. During previous inspections this service user confirmed that she has had regular foreign holidays, regularly goes shopping in Croydon and goes to concerts and shows at the Fairfields Halls. The service users person planning book was examined, this included a list of activities that the service user liked to do during the week. There is a TV, video and stereo in the living room for the service users use. The home encourages service users to keep in regular contact with their families and friends. Mrs Bheecarry 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. Mrs Bheecarry stated that on Saturday evenings service users plan what they wish to eat for the rest of the week. Menus are drawn up and shopping is purchased however Mrs Bheecarry said that sometimes the service users change their minds and request something that is not on the menu. In this case Mrs Bheecarry records what service users have instead. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 user plans include details of their personal care needs and the ways in which staff should work with the individual to meet them. Both service users at the home are diagnosed Learning Disabilities with some Mental Health issues. Mrs Bheecarry and her husband were both previous Registered General Nurses however she is no longer registered. Her husband is still registered as a Mental Health Officer. Both service users are registered with a local General Practitioner. None have specialist medical conditions however should the needs of the service users change then Mrs Bheecarry stated that she would seek support and training to enable staff to support the service user. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 15 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.V322107.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and the service users are confident that any concerns they may have are listened to and acted upon. EVIDENCE: Mrs Bheecarry stated that there had been no complaints received by the home since the last inspection. The home has a copy of Croydon Councils Protection of Vulnerable Adult Policy. Mrs Bheecarry has developed a procedure for use in the home that should result in the necessary notifications to those agencies that are outlined in the statutory procedure. Mrs Bheecarry provided evidence that staff had attended adult protection training in January 2005. Mrs Bheecarry and her husband attended adult protection training in 2003. It is recommended that both the registered provider’s and staff attend refresher training on adult protection. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. EVIDENCE: The home is suitable for the needs of the current service users. Service users bedrooms have been decorated to their own personal choices. Service users spoken to during previous inspections said that they were happy with the home and their rooms. The lounge is small and contains a small television, video a coffee table and comfortable chairs, the home also has a dining area this has a table and three chairs. An extension has been added to the property so that the home can offer day services to the service users. This has been agreed with Croydon Social Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 18 Services and the home also offers day services to a small number of service users from other homes. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team have had relevant training enabling them to meet the needs of the service users living at the home. The registered provider needs to ensure that the staff team receives regular supervision so that the service users benefit from having a consistent approach to their needs. EVIDENCE: Mr and Mrs Bheecarry work at both 164a and 170 Oval Road. Mrs Bheecarry stated that three members of staff are employed at the home. One member of staff works full time and two staff work part time. The full time member of staff has completed an NVQ level 3 in care and is now completing NVQ level 4 the Registered Managers Award. Mrs Bheecarry stated that this member of staff might at some stage take over as the registered manager. Two staff files were examined; one included a copy of their NVQ 3 qualifications. Mrs Bheecarry stated that the two part time members of staff are attending NVQ 3 courses. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 20 There were certificates indicating that these staff had attended health and safety, fire safety, moving and handling, food hygiene and first aid, adult protection and medication training. Staff records included a recent photograph, a Criminal Records Bureau Check, passport and two references. It was recommended at the recent inspection at Mrs Bheecarry’s other care home that staff references are taken up on company headed paper and or include a company stamp. Mrs Bheecarry could not provide evidence that staff receive 1-1 supervision. She stated that she is currently reviewing the homes policy on supervisions. The registered provider must ensure that all members of staff receive a formatted recorded supervision six times a year. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mr and Mrs Bheecarry are working on areas of weakness identified during a recent inspection at their other care home 164 Oval Road. Improvements made at that service have also been implemented in 170 Oval Road. EVIDENCE: Mrs Bheecarry has completed the NVQ 4 qualification in Management and Care. Mrs Bheecarry and her husband were both previous Registered General Nurses however she is no longer registered. During an inspection at 164a Oval Road in October 2006 (Mrs Bheecarry’s other care home) Mrs Bheecarry produced an action plan for the home and some service users questionnaires. Service users relatives have also been asked for their comments about the home and service users hold regular Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 22 meetings. Mrs Bheecarry stated that she is currently reviewing the homes quality assurance/monitoring systems. It is recommended that the registered provider use standard 39 of the National Minimum Standards to develop an appropriate quality assurance/monitoring system for the home. Mrs Bheecarry produced Landlords Gas Safety Certificate 25/09/06 and Portable Appliance Testing was last carried out on the 29/10/06. Mrs Bheecarry produced the current certificate of liability insurance expiry date 09/05/07. Mr Bheecarry stated that 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. Following the recent inspection at 164a Oval Road Mrs Bheecarry contacted the LFEPA for advice on fire safety. The fire officer sent advice on fire safety to the home. Mrs Bheecarry produced the homes fire safety records. The records showed that the fire/smoke detectors had been tested on a regular weekly basis. Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 23 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 Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 24 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 YA36 Regulation 18 (2) Requirement The registered provider must ensure that all members of staff receive a formatted recorded supervision six times a year. Timescale for action 31/12/06 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 YA6 YA9 Good Practice Recommendations It is recommended that the registered provider write to the service users care manager requesting a copy of the care plan to keep on the service users file. It is recommended that the registered provider contacts the service users care manager to consider/develop guidelines for the home to follow in the event of the service user making accusations/allegations against staff or other service users. It is recommended that both the registered provider’s and staff attend refresher training on adult protection. It is recommended that the registered provider use standard 39 of the National Minimum Standards to develop an appropriate quality assurance/monitoring system for the home. 3. 4. YA23 YA39 Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Oval Road (170) DS0000028159.V322107.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!