Inspection on 25/05/05 for Samuel Close (1, 2 & 3)

This inspection was carried out on 25th May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Samuel Close (1, 2 & 3) 15/11/06

Samuel Close (1, 2 & 3) 20/12/05

Samuel Close (1, 2 & 3) 30/12/04

Samuel Close (1, 2 & 3) 26/07/04

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 1,2&3 Samuel Close Samuel Street Woolwich London SE18 5LR Lead Inspector Keith Izzard Unannounced 25 May 2005 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. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Samuel close (1,2 & 3) Address Samuel Street, Woolwich, London SE18 5LR 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) 020-8855-0329 020-8855-6261 Staff@Milbury4.freeserve.co.uk Milbury Care Services Limited Mr Jimmy Lendor Care Home 17 Category(ies) of Learning Disability male and female 16, registration, with number Learning Disability over 65 female 1 of places 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: One place registered for Learning Disability (E) in respect of named service user only. Imposed 26 October 2004. Date of last inspection 26 July 2004 Brief Description of the Service: Numbers 1, 2 and 3 Samuel Close are three linked bungalows situated in a residential close in Woolwich. Each house provides board and nursing care for between five and seven adults with learning disabilities. The three houses provide services for different needs. House one is for people with learning disabilities who have challenging behaviour, house two for people with physical disabilities as well as learning disabilities and house 3 for people with learning disabilities who may also have other needs. Each house functions as a distinct group with it’s own front door, house leader, staff group, and communal facilities. Service users in each house eat together and share a communal lounge. There is an overall registered manager for the three houses, and some service users socialise with or visit other service users in different houses. The home is one of a group of six homes for adults with learning disabilities in the London Borough of Greenwich managed by Milbury Community Services a National Organisation. The home has strong links with the Greenwich Community Learning Disabilities Team (C.L.D.T) a service for people with learning disability in Greenwich. The CLDT are involved in placements in the home, and the service users’ life plan reviews. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over seven hours in total on 25th and 31st May 2005. There was a subsequent unannounced inspection on 16th June 2005 as the result of an anonymous complaint regarding medication received by CSCI. At that visit an immediate requirement was made and this was complied with immediately. This inspection included talking to residents, staff and management. Inspecting records, safety systems and the premises. What the service does well: What has improved since the last inspection? The service user guide has been updated. Written contracts for residents have now signed by both the manager and residents, or their representatives. Night care staff members have been included in fire drills and all staff updated in the use of fire prevention equipment. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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) 1-5 The home provided adequate information about the service. Introductory visits are part of the policy and procedure for the home and are part of the admission process. All service users have written contracts. EVIDENCE: The Statement of Purpose and Service User Guide have been updated in response to a previous requirement and the documents seen now comply with this Standard and with the Regulations. How well the home meets Standard 2, has yet to be assessed in practice, as no new residents had been admitted to the home since the introduction of the National Minimum Standards. The contracts for service users have now been signed by service users, their relatives, or advocates and by the manager of the home. This was a previous requirement that has now been complied with. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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) 6-10 From the evidence provided staff members worked in a professional and caring way to meet resident’s individual care needs. EVIDENCE: Care provided to two residents was tracked. Care plans were well written and respectful to residents. They were supported by an up to date assessment of need. Risk assessments were comprehensive and up to date and covered areas such as management of epilepsy, moving and handling, bathing and the use of cot sides. Staff members interviewed said they do their best to involve residents in decision- making based on their individual communication and comprehension. Owing to the level of communication difficulties of service users this Standard is a challenge for staff members. Good records are maintained of the likes and dislikes of individual service users and the staff interviewed were aware of these, this information was readily accessible for new workers or agency / bank staff. Staff members were observed to be communicating with residents and involving them in whatever was going on. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 10 Life plans were up to date and had been prepared in the presence of the resident. Life plans had clear goals set with planned achievement dates. Resident’s records were well maintained, safely stored in lockable cabinets. At the time of inspection two residents were preparing for a trip to Florida and two others were going to the south coast for a week as part of their annual holidays. None of the residents have the ability to manage their own finances. An accountable and independently audited system was examined and records were well recorded with ledgers tallying with the remaining cash float within individual resident accounts. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 standard(s) 11-17 Attention has been given to meeting the leisure and social needs of the residents. The meals provided were varied and planned to meet the resident’s choice and preferences and in accordance with advice from Speech and Language Therapists in respect of special diets for some residents. EVIDENCE: All residents attended a day centre for four days per week and some are involved in cookery and literacy classes. The day centres provided opportunities for residents to develop individual skills. The weekday spent within the home is an opportunity for service users to be actively involved with their key worker when activities or shopping trips may be organised. Only one of the residents has been assessed as having the capacity to benefit from further education, but none to seek permanent employment. The resident referred to has bought her own laptop and is currently attending a local college to learn computing skills. This is commendable. Staff planned outings and activities around resident preferences and activities records showed these included day trips, meals out, pub visits and support to access local entertainment and leisure activities. At the time of the inspection 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 12 two separate holidays were being provided for two sets of residents, one to Disneyland in Florida and the other to the south coast. Staff members actively encourage family contact and support and reported that positive relationships with relatives had been built up. The three kitchens, one for each unit, were clean, tidy and well stocked with fresh and frozen foods. All staff involved with food had been trained in food safety and foods were stored properly: fridge and freezer temperatures monitored daily. Menus seen showed a varied diet was provided and evidence was available that specific nutritional needs had been obtained from dieticians, speech and language therapists and other health professionals. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 standard(s) 18-21 Resident’s needs were being met based on assessment of need and with the involvement of the resident, as far as this could be achieved, as most residents have severe communication difficulties. Medicines were assessed as safely managed on the day of inspection. However a subsequent unannounced inspection following an anonymous complaint made to the CSCI and prior to the publication of this report, resulted in an immediate requirement being made. This was in relation to ensuring medication is only signed as being given after it has seen to have been taken. This was complied with immediately. EVIDENCE: Care plans showed the level of personal care required and how this was to be provided. The care plans examined were up to date and included comprehensive risk assessments Residents were supported to access health services appropriately and had these provided either in the home or attended local clinics and surgeries Medicines were generally well managed. Because there were concerns with drug errors in the past, the manager had introduced a system to check medicines weekly. As mentioned above a subsequent unannounced inspection 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 14 on16th June 2005 resulted in an immediate requirement being made in relation to medication. Requirement 1. The issues in relation to Standard 21 have been addressed. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 standard(s) 22-23 Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. However, staff members must be provided with refresher training on adult protection, whistle-blowing and the complaints procedure. EVIDENCE: Since the last inspection one allegation of physical abuse against a resident from a member of staff was investigated by CLDT. The allegation was upheld and the member of staff dismissed. Two other staff members received disciplinary warnings regarding their lack of response in reporting the incident. Requirement 2. No complaints were received by the home but one anonymous complaint was received by the CSCI direct and is already referred to under Standard 20 to do with medication. Requirement 3. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 standard(s) 24-30 One requirement and four restated requirements have not been complied with in response to previous inspections in relation to Standard 24. This is unacceptable. The CSCI will be seeking an explanation from the provider in respect of non- compliance. In relation to Standards 25-30 the home met these Standards. EVIDENCE: Carpeting in house 1 had not been replaced; two previous timescales of 1/12/04 and 1/05/05 were not met. A general requirement to ensure that shower rooms and toilets are refurbished, previous timescales of 1/01/05 and 1/5/05 were not met. A previous requirement that the state of internal decorations and furnishings must be reviewed and the results submitted in writing to the CSCI, had not been complied with, timescale given 1/06/05. A previous requirement that the kitchen units and extractor fan be repaired or replaced in house 2 was not complied with, timescale 1/06/05. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 17 A previous restated requirement that the paved area to the rear of the houses must be levelled for the safety of service user was not complied with, timescales given 1/01/05 and 1/06/05. Restated Requirements 4, 5, 6, 7 8 & 9. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The staff team had the skills, support and training to meet the resident’s needs. EVIDENCE: Staff members interviewed presented as having a friendly yet professional relationship with residents and spoke knowledgably of resident’s individual needs, likes and lives. Training records showed that a range of appropriate training had been provided and future training planned for. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 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) 39,42 A system to record the views of residents must be developed to assist staff in their monitoring of how the home operates is developed and reviewed. Overall, most of the records and routine examination of equipment and the building in respect of health and safety matters was comprehensive and up o date. EVIDENCE: Evidence of the recording of residents’ views in respect of the running of the home and the service provided for them was not available and must be provided. Requirement 10. A previous requirement that all call points are tested on a weekly basis and that two call points be re-sited to able this testing was not complied with. The previous timescale was 1/04/05. Any recommendations or requirements 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 20 arising from the recent inspection by the local fire officer must be complied with. Restated Requirement 7 and Requirement 11. Other records examined were up to date and comprehensive, however, hoisting equipment examined did not have stickers applied following routine six monthly examinations. It was recommended that stickers should be applied to assist at times of inspection. Recommendation 1. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1,2&3 Samuel Close Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 22 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 20 Regulation 13 Requirement The Registered Person must ensure that the giving of medication is only signed on the MAR sheet when it has been observed to have been taken. The Registered Person must ensuire that all staff receive refesher training in adult protection and whistle blowing. The Registered Person must ensure that all staff are aware of the complaints procedure. The Registered Person must ensure that the carpeting in house 1 is replaced as soon as possible.Restated Requirement (timescale of 1.05.05 not met) The Registered Person must ensure that shower rooms, toilets and associated fittings are in a good state of repair and specifically one shower and toilet repaired and another the floor and wall re-sealed in house 3.Restated Requirement timescale 1.05.05 not met) The Registered Person must ensure that the internal furnishings and decoration throughout is reviewed and the outcomes submitted in writing to G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Timescale for action 16.06.05. 2. 23 13 1.10.05 3. 4. 23 24 17 23 1.09.05 1.10.05 5. 24 23 1.10.05 6. 24 23 1.10.05. 1,2&3 Samuel Close Version 1.30 Page 23 7. 24 23 8. 24 23 9. 24 23 10. 39 24 & Schedule 2 11. 42 23 the CSCI. Restated requirement, timescale 1.06.05 not met. The Registered Person must ensure that all call points are tested on a weekly basis and specifically two are re-sited to enable testing of them to be facilitated. Restated Requirement (timescale 1.04.05 not met) The Registered Person must ensure that the kitchen units and extractor fan are adequately repaired or replaced in House 2 restated requirement previous timescale 1.06.06 not met. The Registered Person must ensure that the paved area to the rear of the houses is levelled to ensure the safety of service users.Restated Requirement. (timescale 1.06.05 not met) The Registered Person must ensure that residents are consulted about the operation of the home and conduct surveys of their views, or their representatives,annually. The Registered Person must ensure that any requirements or recommendations arising from the Fire Officers report are implemented within timescales given. 1.09.05 1.11.05 1.11.05 1.12.05 1.09.05 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. Refer to Standard 42 Good Practice Recommendations The Registered person should ensure that when hoists and mobility aids are inspected six monthly they have date stickers attached to them. 1,2&3 Samuel Close G51-G01 S6770 Samuel Close V224562 25-05-05 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Sidcup Area Office River House, 1 Maidstone Road, Sidcup Kent DA14 5RH 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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