Inspection on 09/06/06 for Riverside Drive

This inspection was carried out on 9th June 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 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Riverside Drive 11/05/09

Riverside Drive 19/06/08

Riverside Drive 24/04/07

Riverside Drive 01/02/06

Riverside Drive 08/08/05

Riverside Drive 14/10/04

Riverside Drive 18/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Riverside Drive 112 Riverside Drive Mitcham Surrey CR4 Lead Inspector Adrian Gordon Unannounced Inspection 9th June 2006 10:30 Riverside Drive DS0000033994.V298755.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 Riverside Drive DS0000033994.V298755.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. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riverside Drive Address 112 Riverside Drive Mitcham Surrey CR4 020 8640 8279 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) www.merton.gov.uk/housingsupport London Borough of Merton Care Home 8 Category(ies) of Learning disability (6), Physical disability (2) registration, with number of places Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 10th February 2006 Brief Description of the Service: 112 Riverside Drive is a care home providing personal care and accommodation for eight adults with learning disabilities, up to two of whom may have physical disabilities. The home is staffed and managed by the London Borough of Merton social services department. The premises are owned by a housing association. The home was purpose built and is located on a site set back from a residential road in Mitcham. All residents are provided with their own single bedroom. One bedroom is furnished with en suite facilities and tracking. A lift provides access to the first floor. An enclosed garden is provided to the rear of the premises. Parking is available to the front of the home. The home is close to bus and tram links. Information about the service is available in the Statement of Purpose and Service User Guide. Fees are not applicable to this service as it is an in-house service funded by the London Borough of Merton. However, residents are expected to pay towards holidays. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over the course of one day. The inspection consisted of examination of records, a tour of the premises, observation of care practice, talking to two residents , four members of staff and the manager. Social workers were invited to give feedback but there has been no response. The manager was asked to send out feedback questionnaires to relatives or friends of residents, but again, there has been no response. What the service does well: What has improved since the last inspection? What they could do better: There are a number of requirements made which are outstanding from previous inspections. The registered person must ensure these are now met or enforcement action may be considered. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 6 Prospective residents must have a full needs assessment before being admitted to the home. Care planning and risk assessment documentation must be up to date, signed and dated. Action must be taken to ensure that all residents have access to suitable transport. In order to safeguard residents welfare all staff must be trained in the protection of vulnerable adults. A photo of each member of staff must be included in their individual files. All staff must receive regular supervision and have a training needs profile. The manager must make an application to be registered with the CSCI. The registered person must ensure that there is a formal quality review system and that monthly monitoring visits are taking place. 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. Riverside Drive DS0000033994.V298755.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 Riverside Drive DS0000033994.V298755.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective residents and their families are able to make an informed choice about the suitability of the home, however a lack of information for staff means they may not be aware of particular needs. EVIDENCE: Work has started on making the service user guide more accessible to residents. This is being done through the use of symbols and pictures. The complaints procedure has been changed in this way and should give residents a better understanding of what they can do. One prospective resident has been visiting Riverside Drive before moving in. The father visited during the inspection and said that he was happy with the involvement he had had with the home. He also said he will attend a future staff team meeting before the move. This will allow staff to get a good picture of the new resident and to build up a relationship with the father. Information about the new resident consisted of daily support guidelines and a Statement of Need, both of which were over a year old. There was not a full needs assessment. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Completed care plans support residents in meeting goals, however residents without an up to date care plan are disadvantaged. EVIDENCE: A new form is being developed to record care plans but this has not been introduced yet. Existing care plans were seen to cover a wide range of support needs, setting achievable goals for the residents. One care plan showed thought had gone into considering a residents religious needs through attendance at church. The manager said that residents are aware that they keep their own care plan but none had requested this. Resident files did not show consistency. In one case there had been a recent review in May 2006 but the care plan was not signed or dated. Another Care Plan was originally dated 23/8/05 but had been signed again on 15/4/06 without any changes being made. This was despite the fact that information Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 10 about sexuality made reference to another resident who left the home last year. Risk assessments are in place and are signed and dated but two of these had not been recently updated being over a year old. The registered persons must ensure that Care Plans and risk assessment are regularly reviewed, signed and dated. This issue was noted at the previous inspection. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to take part in appropriate activities of their choosing which allow for personal development. EVIDENCE: All residents have their own ‘community day’ during which they spend time outside the home with their keyworker. Residents confirmed that they enjoy going out and are able to do activities that they prefer. Resident records contain good information on the likes of dislikes of residents including Personal Care Plans which provide good information on different needs, including sexuality and cultural preferences. One resident does still not have access to suitable transport to take them out and so is disadvantaged in the activities they can attend. The manager confirmed that a vehicle is being purchased with the assistance of Disability Living Allowance money, which will be exclusively for this residents use. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 12 Residents confirmed they enjoy the meals provided. Menus showed that there was a good range of meals and fruit is available at all times. A record of food eaten at mealtimes is now maintained. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good support is in place to meet residents health needs. EVIDENCE: Staff were observed to allow residents to make choices and decisions about how they preferred to live, for example one resident was able to lie in bed late on the day of inspection. Other residents showed they can express their personality by deciding how they wanted their hair cut or by choosing the colour of their nail polish. All residents had detailed Health Action Plans and are registered with local doctors. Residents have access to other health support if required. One resident is currently getting regular visits from a district nurse to help with a particular health need. There are good links with the community learning disability team. Adaptations in the home support residents with physical disabilities. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 14 Medication systems have improved since the last inspection. Medication administration sheets are clear and have been filled in correctly and specimen signatures for staff are available at the front of the file. Medication profiles are in place for each resident although these did not include a photograph. Staff have been attending accredited training on medication and this is ongoing. It was noted that a doctor had recently changed the dose of one residents’ medication but the blister pack still contained the original dose until a new prescription had been completed. Although staff had taken this into account when giving out the medication, by halving the tablet, there was an increased risk of an error. Care must be taken to ensure that when there are changes to medication, blister packs are changed and contain accurate amounts. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. In order to protect residents all staff must be trained in the prevention of adult abuse. EVIDENCE: There have been no complaints since the last inspection. Records of previous complaints and are kept on file. The complaints procedure has been written in a way which makes it more accessible to residents. Two residents said that if they are not happy about something they talk to staff or the manager. The home follows the London Borough of Merton’s procedures for the protection of vulnerable adults (POVA). The manager stated that training for staff in this area is ongoing, however two staff fed back they had not had any recent training in the last year. A number of staff files also showed no evidence of POVA training. All staff must be made aware of the policies and procedures in place to prevent residents being at risk of harm or abuse. The recording system for monitoring money held on behalf of service users is clear and easy to understand. The admin worker checks the record are correct on a regular basis. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a clean, comfortable and homely environment. EVIDENCE: Riverside Drive is laid out over two floors. All areas were seen to be clean and tidy. Furniture and décor in the lounge/dining area makes it feel very homely and it was seen to be a focal point in the home for residents. The kitchen is well equipped and accessible. The lounge leads out to a well maintained garden which had a number of seating areas for residents to enjoy. Residents have their own bedrooms and these were personalised to individual taste. The relative of a prospective resident was observed to discuss colour preferences for the walls of a bedroom with the manager. One resident commented that the bed in their room was unsuitable for their needs, being too small and a risk to their physical safety because they often had seizures at night. This must be assessed by a qualified Occupational Therapist. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff are well informed about the needs of residents, however staffing levels must be reviewed in order to ensure that these needs can be met in practice. EVIDENCE: The manager said that after a recent period of recruitment the home is fully staffed and no longer needs to make use of agency staff. This was confirmed by the rota. Pictures of staff members were seen on a wall at the entrance to the home. Staff were observed to interact well with residents, for example one member of staff was painting the nails of a resident who was having a party. Staff spoken to were well informed about the needs of residents. However one resident who had asked to go out was given conflicting information about when this might be possible and the time that was agreed with them kept being changed. This eventually led to the resident becoming frustrated and kicking out. Although staff were aware that this behaviour was common, there was not a consistent approach to prevent it from happening. There are a minimum of three staff on in the daytime. On the day of inspection staff were not able to take all the residents out and the manager had to assist at times. Two staff commented that staffing levels were not sufficient and were Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 18 concerned about being able to manage when a new resident is admitted. The home must ensure that staffing levels are reviewed to ensure that the individual needs of residents are met. Staff files kept at the home did not contain recruitment information. However, the manager was able to show email correspondence with Head Office confirming when new staff have references and Criminal Records Bureau checks. A photo of each staff member must be included in their personal files. Induction and probation records were seen to be well maintained for a recent new staff member. This person confirmed that they had been well supported in this period. Staff records showed that yearly appraisals are taking place but supervisions were not being undertaken regularly. Training needs are discussed in appraisals and staff are continuing to attend medication and first aid training. More work must be done in ensuring that all staff have a training needs profile Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 19 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, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Monitoring systems must be improved in order to ensure that residents welfare is promoted. EVIDENCE: The manager of the home is suitably qualified but has not yet applied for registration with the CSCI. This was a requirement at the last inspection. The manager must ensure that this application is now submitted as a priority. Only one monthly monitoring visit report has been forwarded to the CSCI in the last 6 months and there were not copies of every month kept at the home. The manager said that these visits do not appear to be happening regularly. These must be completed every month and a report sent to the manager and the CSCI. A quality monitoring and assurance programme is still in development. This was a requirement at the last inspection and must now be implemented. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 20 Records of resident meetings are maintained which show good involvement from residents, however meetings were not occuring regularly. One was dated 1/2/06 and a more recent one had no date. A poster on the wall publicised a Service Development Officer in Merton who residents could contact if they were not happy about something. One resident told me that they didn’t know what this meant. Further work must be done to ensure residents are able to understand information that is aimed at them. Health and safety records are well maintained and all necessary checks are carried out, including regular fire alarm system checks and fire drills. It was noted that at the top of the staircase there was a ‘bubble’ under the carpet which is a possible trip hazard. It was confirmed that this had been reported as a priority repair. Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 21 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 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes 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 14(1) Requirement The registered person must ensure that prospective residents are only admitted once a full up to date needs assessment has been obtained. The registered persons must ensure that care planning documentation is signed and dated and reviewed at least six monthly or more frequently if required. (Previous timescales of 20/03/05 and 15/05/06 not met) The registered persons must ensure that risk assessments are signed, dated and kept under review. (Previous timescales of 01/10/05 and 15/05/06 not met) The registered persons must take action to ensure that all residents have access to suitable transport facilities to meet their needs. Timescale for action 01/07/06 2 YA6 15 28/07/06 3 YA9 13(4) 28/07/06 4 YA13 12 31/08/06 Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 Page 23 5 YA20 13(2) (Previous timescales of 01/10/05 and 15/05/06 not met) The registered person must ensure that medication profiles contain a photo of each resident and that where changes in medication occur this is accurately reflected in blister packs. The registered person must ensure that all staff are trained in the Protection of Vulnerable Adults. 28/07/06 6 YA23 13(6) 31/08/06 7 YA26 18(1)( c) The registered person must 31/07/06 ensure that resident bedrooms meet their needs and that beds are assessed by an Occupational Therapist if needed. The registered person must ensure that the number of care staff on shift is determined according to the assessed needs of residents. 31/07/06 8 YA33 18(1)(a) 9 YA34 19, Schedule The registered person must 2 ensure that an up to date photo of each staff member is held in their file. (Previous timescale of 01/05/06 not met) The registered person must ensure that all staff have a training needs profile. (Previous timescale of 15/05/06 not met) The registered person must ensure that all staff receive regular, formal supervision. The registered person must make an application for the registration of the home DS0000033994.V298755.R01.S.doc 31/07/06 10 YA35 18(1)(c) 31/07/06 11 12 YA36 YA37 18(2) 8 31/07/06 01/07/06 Riverside Drive Version 5.2 Page 24 manager. (Previous timescale of 15/05/06 not met) 13 YA39 24 The registered person must ensure that a regular review of the quality of care provided is carried out, taking into account the views of residents and other stakeholders. A copy of the report produced following the review of the service must be provided to the CSCI. (Previous timescale of 15/05/06 not met) The registered person must ensure that a monthly monitoring visit is carried out and a report forwarded to the CSCI. 31/08/06 14 YA39 26 28/06/06 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 Refer to Standard YA1 Good Practice Recommendations The registered person should ensure that the service user guide is made available to residents in an accessible format. The registered person should ensure that information aimed at residents is accessible and understood by them. 2 YA39 Riverside Drive DS0000033994.V298755.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Riverside Drive DS0000033994.V298755.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. 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