Inspection on 15/11/05 for Park View

This inspection was carried out on 15th November 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Park View 18/11/08

Park View 26/06/06

Park View 10/06/05

Park View 23/11/04

Park View 12/07/04

Park View 18/02/04

Park View 18/11/03

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

CARE HOME ADULTS 18-65 Park View 9 - 11 Park Avenue Mitcham Surrey CR4 2EQ Lead Inspector Liz O`Reilly Unannounced Inspection 15th November 2005 11:30 Park View DS0000027247.V270778.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 Park View DS0000027247.V270778.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. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Park View Address 9 - 11 Park Avenue Mitcham Surrey CR4 2EQ 0208 646 6694 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 Feeroz Hosanee Mr Feeroz Hosanee Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (6) Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 2005 Brief Description of the Service: Park View is a registered care home for up to six residents with mental health needs. The home is in a residential area of Mitcham, close to local shops and transport services. Park View is made up of two residential properties which have been joined together. The property is owned by Mr Hosanee who also owns a second home in this area. Park View is not identifiable as a care home. The aims and objectives of the home have been set out in the Service Users Guide and Statement of Purpose copies of these documents are available in the home. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector on 15th November 2005 over three hours. The inspector had the opportunity to speak with two residents, one member of the care staff and the registered manager of the home. What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that any references for new staff are sought directly by the home. The use of references addressed “to whom it may concern” are not acceptable. The manager must ensure that in future all new staff are required to provide a full employment history so that any gaps in employment can be explained. The kitchen for the home needs to be redecorated and refurbished within the next twelve months. Once completed a copy of the report following the annual review of the service must be provided to the CSCI. Park View DS0000027247.V270778.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. Park View DS0000027247.V270778.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 Park View DS0000027247.V270778.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&4 A copy of the care management assessment is sought for any new residents to make sure that staff are provided with information on the needs of individuals before they move in. Prospective residents are encouraged to visit the home before making any decision about moving in. EVIDENCE: There have been no new admissions to the home since the last inspection. The manager confirmed that an up to date care management assessment is obtained before anyone new is admitted to the home. Staff from the home visit people before they are admitted to carry out their own assessment. These assessments make sure that staff have clear information on the strengths and needs of any new resident. Prospective residents are encouraged to visit the home before making any decision about moving in. These visits can include sharing a meal with the existing residents, staying for the day or a few days depending on the needs of the person. Park View DS0000027247.V270778.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&9 Care planning has improved since the last inspection. Suitable risk assessments are carried out to support residents to maintain or gain independence. EVIDENCE: Staff and some of the residents have worked to produce more individualised care plans. One resident has produced their own weekly plan of activities according to their personal needs and wishes. Care plans provide information on the mental health, physical, social and emotional needs of individuals. Any arrangements for supporting residents to manage their finances is included in the care plan. Care plans are reviewed on a regular basis to make sure they provide up to date information. Staff work with residents to develop or maintain independence at a pace which is comfortable to the individual. Staff are aware that risk taking is part of developing independence and appropriate individual assessments are carried out to support this. Residents confirmed that they were encouraged and Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 10 supported in making their own decisions about their lives with staff providing support if needed. Risk assessments cover issues such as self harm, fire, harm to others, absconding and drugs or alcohol. The assessments are reviewed annually or more frequently should there be any changes which ensures that staff are supplied with up to date information. Staff on duty maintain a daily record for each resident. The standard of recording has improved since the last inspection. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 & 17 Staff support residents with education, employment and activities according to individual wishes. Residents are encouraged to maintain relationships with family and friends. Menus offer a good variety of food with alternatives available at each meal time. EVIDENCE: Residents are encouraged to continue with their own interests and any educational or employment opportunities they wished to follow. Staff encourage and support residents to keep in contact with friends and family. Staff are working with residents to supply a more personalised care plan which will allow staff to offer a more individualised service. One resident has produced their own care plan around activities which included regular attendance at a gym, college courses and carrying on with their own projects. The majority of residents meet with friends and family outside the home. Visitors are welcome in the home at any time. Residents are free to meet with visitors in the privacy of their own room or in the communal areas of the home. One resident keeps in contact with friends via letters. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 12 The majority of residents spend at least part of the day outside the home following their own interests. Activities are available in the home and staff were observed to interact with residents in a positive manner and join in activities. The routines of daily living are flexible to take into account residents activities. Some residents are involved in domestic tasks in the home such as setting tables and sweeping up. One resident told the inspector that they were encouraged to keep their own room tidy but staff would help them with this. All residents are offered a key to their bedroom. At the time of the last inspection two requirements were made regarding the food provided. A snack has been provided between the last main meal of the day and breakfast. A review of the menus has taken place in consultation with residents. The menu has also been amended to include the snack in the evening. Following the review of the menus additional Afro Caribbean options have been included. Residents gave very positive comments on the new menu, the quality and quantity of food provided. Park View DS0000027247.V270778.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, 20 & 21 Staff provide advice and support to residents on personal care. The health and welfare of residents is protected by well managed medication systems. Action has been taken to ensure that up to date records are held on next of kin. EVIDENCE: None of the residents require direct personal care. Staff offer advice and provide support for residents to maintain their own personal care. The health care needs of residents are met with all resident registered with local GP practices. Arrangements are in place for residents to receive optical, dental and chiropody services according to individual needs. The home has contact with local community psychiatric services which can be called upon for advice if required. Records of health care check ups are maintained for each resident. Staff protect the health and welfare of residents by keeping good records of the administration, receipt and disposal of medication. All medication is stored safely. The manager and one senior member of staff have completed accredited training on the management of medication. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 14 At the time of the last inspection two requirements were made in relation to contacting next of kin in the event of death. The home was required to review the procedures in place and ensure that they had accurate contact details of the next of kin for each resident. These requirements were seen to have been carried out. This information will ensure that staff can contact the next of kin of a resident without delay in the event of an emergency. Park View DS0000027247.V270778.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 & 23 A clear complaints procedure ensures that any complaints or concerns raised by residents are listened to and acted upon. The policies and procedures along with staff training assist in protecting residents from abuse. EVIDENCE: The manager has reviewed the complaints procedure to ensure that it remains relevant and up to date. The home keeps a record of any complaint received along with actions taken and the outcome. The home has received no complaints since the last inspection of the home. All staff are provided with training on the protection of vulnerable adults. This ensures that staff are aware of their responsibilities and actions to be taken should there be an allegation or suspicion of abuse. Residents can deposit small amounts of cash in the home for safekeeping. Staff assist two residents to manage their budget. A separate record is kept for each resident. The manager has reviewed how records of residents money held by the home are kept. The new system ensures that any money taken out or deposited into an account is checked by two members of staff and the resident concerned. Park View DS0000027247.V270778.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 & 30 The home is generally well maintained. All areas of the home seen at this visit were clean and tidy. EVIDENCE: Residents stated they felt “very comfortable” in the home and that they liked their bedrooms. Residents stated they were happy with the bathrooms and could manage well without any aids or adaptations. New worktops have been installed in the laundry room. A planned programme for the redecoration and refurbishment of the premises should now be compiled with a copy of the plan supplied to the CSCI. Recently water has caused damage to one of the bathroom ceilings. New plaster board had been installed and the home was waiting for a plasterer to complete the repair. Once completed the manager said that the bathroom would be redecorated. The kitchen for the home is showing signs of wear and tear. Arrangements should be made for the kitchen to be redecorated and refurbished within the next twelve months. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 17 Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 18 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): 32, 33, 34 & 35 Regular training is provided on caring for individuals with mental health needs. Sufficient staff are on duty to meet the needs of the resident group. Agreement has been made on reducing the required staffing levels when the majority of residents are not in the home. Further work needs to be done on seeking appropriate references for new staff to protect residents. EVIDENCE: The manager supplies regular training sessions on a variety of mental health issues. This helps to ensure that the staff group are well informed on the strengths and needs of the individuals in their care. Residents gave very positive comments on the staff group and felt that staff respected their privacy and treated them as individuals. Staff were viewed as “helpful” and “good at listening”. The home is required to have a minimum of two staff on duty at all times. The majority of residents spend much of the day out of the home. At this visit during the day only two residents were in the home. It has been agreed that where there are less than three residents in the home then a minimum of one member of staff should be on the premises. When there are three or more residents then two staff should be available. These staffing levels must be Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 19 kept under review to make sure that they continue to meet the needs of the residents in the home. At night one member of staff sleeps on the premises. The manager lives in the same street as the home and is available to offer assistance and or advice during the night. The manager keeps a record of any instances when the person in the home at night has been called out. This ensures that the staffing levels are kept under review. In order to protect residents the manager carries out pre employment checks on each staff member. These include criminal record bureau checks, identity checks and two references. It was noted that in one instance the manager had accepted pre written “to whom it may concern” references. The manager must make sure that all references are sought directly by the home. Staff are provided with good opportunities for training. As well as the in house training on mental health needs staff have also completed training in risk assessment and risk management, emergency life support, health and safety and the protection of vulnerable adults. Two members of staff has completed NVQ level two. One member of staff was considering taking part in NVQ level three training. This training ensures that residents are supported by a well informed staff group. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 20 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): 37, 38, 39 & 42 The manager is continuing with training . Residents are consulted and provided with opportunities to influence the way the home is run. Staff carry out regular checks on the building to protect the health and safety of residents. EVIDENCE: The manager is a registered mental nurse. He is also in the process of NVQ level four training which is expected to be completed in January 2006. Residents meetings are held once a month. Records showed that residents discuss the food provided, outings, activities and various aspects about living in the home such as choice, independence and health and safety. These meetings offer residents an opportunity to voice any concerns and influence the way the home is run. The manager has devised questionnaires for residents, families, friends and other health and social care professionals. This information will be used to produce an annual assessment of the service set against the stated aims and Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 21 objectives. Once completed a copy of the report produced must be provided to the CSCI. Appropriate checks were seen to be recorded on the fire alarm system and hot water temperatures. Cleaning materials are stored and used safely. Staff have been provided with training on food hygiene, fire safety and first aid. The home has received visits from environmental health and the fire brigade over the last year. Any recommendations made by these organisations have been implemented. The checks carried out on the building along with the training assists in ensuring the health and safety of residents, staff and visitors to the home. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 22 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 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park View Score 3 x 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 3 x DS0000027247.V270778.R01.S.doc Version 5.0 Page 23 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 YA34 Regulation 19(1)(c) Sch 2 Requirement The Registered Person must ensure that two written references are sought and received for all staff prior to commencing work in the home. The Registered Person must ensure that a full employment history is sought for any new members of staff. The Registered Person must supply to the Commission a copy of the report produced following the annual review of the service. The registered persons must supply to the Commission a budget statement for the home. (timescales of 01.11.04 and 21.02.05 not met) Timescale for action 01/01/06 2. YA34 17(2) Sch 4 (6)(a) 24(2) 01/01/06 3. YA39 01/05/06 4. YA43 25 01/05/06 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. Park View Refer to Standard YA24 Good Practice Recommendations The registered persons should compile a programme for DS0000027247.V270778.R01.S.doc Version 5.0 Page 24 2. YA24 the redecoration and or refurbishment of the premises, a copy of which should be supplied to the Commission. The registered persons should make plans for the refurbishment of the kitchen area and the redecoration of the bathrooms in the home. Park View DS0000027247.V270778.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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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