Inspection on 07/02/07 for Southampton Way, 296-298

This inspection was carried out on 7th February 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southampton Way, 296-298 12/01/09

Southampton Way, 296-298 12/01/06

Southampton Way, 296-298 04/03/05

Southampton Way, 296-298 22/09/04

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

CARE HOME ADULTS 18-65 Southampton Way, 296/298 296/298 Southampton Way London SE5 7HQ Lead Inspector Pam Cohen Unannounced Inspection 7th February 2007 01:00 Southampton Way, 296/298 DS0000007098.V329201.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 Southampton Way, 296/298 DS0000007098.V329201.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. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southampton Way, 296/298 Address 296/298 Southampton Way London SE5 7HQ 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) 020 7252 6748 020 7252 6748 admiin@sway.equinoxcare.org.uk Equinox Mrs Oluwatoyin Ann Adesoye Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12 January 2006 Brief Description of the Service: Southampton Way is a registered care home managed by Equinox to provide 24-hour care for 13 males with long term mental health and/or substance misuse problems. The service users are mostly Afro-Caribbean. The home is on three floors and accommodation is in fully equipped studio flats. There are also communal facilities of a laundry, kitchen, lounge/dining room, smoking room and a garden. There is on street parking. The home is near Peckham High street, rail and bus links and community health and leisure facilities. On the day of inspection there were no vacancies and the weekly fees were £650. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in the afternoon of February 7th. The manager, deputy manager and staff facilitated the inspection. The inspector was also able to speak to a service user and to the care co-ordinator from the high support team who works with the service users in the home. What the service does well: What has improved since the last inspection? 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. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 6 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 Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 7 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): 1,2,4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are able to make an informed choice about coming to Southampton way through information provided and a programme of visits. Their needs are assessed before admission. EVIDENCE: The home has an accessible and user-friendly Statement of Purpose and Service User Guide which provide all necessary information for prospective service users. Files seen for new service users had assessments on them and information from the multi-disciplinary team. The decision as to whether the home can meet the needs of a prospective service user is made with the staff team. There is a good gradual process for admission with overnight and weekend stays before the final decision is made to move in. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 8 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): 6,7,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are able to follow the life style they wish, with support from staff to minimise harmful behaviours. They can be confident that information about them is secure. However service users cannot always be sure that the support that they receive is reflected in their individual plans. Their safety and that of staff needs to be protected by more thorough assessment of how to manage perceived risk. EVIDENCE: The care co-ordinator from the local high support team, who is involved with all service users on an ongoing basis, had no reservations about the care given at Southampton way. He cited the fact that three service users were enabled to move on to less supported care last year, which he sees as an achievement on the part of the home. The service user who spoke to the inspector was also satisfied that all his needs were being met. However the care plans seen, continue to fail to reflect this good practise. Assessments are sparse and not individualised; most service users’ needs being assessed under the same three Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 9 or four headings. Service users’ changing needs were not always documented on their care plan. Goals were often open-ended and so there was no way to measure achievement and go on to set further goals. Not all areas of risk had a management strategy as to how to manage that risk. This is of most concern in relation to some severe challenging behaviour that can be exhibited by some service users. There were good risk assessments seen however which supported service users to go on holiday. A service user confirmed that he is supported to make his own decisions about his lifestyle. Files and daily notes show this to be true for other service users. Key working sessions and the handover witnessed, show that this is within a framework of seeking to minimise any harmful behaviour. Service users’ files and information about them is kept secure. Computers are password protected. There is a confidentiality policy and the organisation is registered under the data protection act. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported and enabled to have as fulfilling and varied a life as possible. EVIDENCE: Staff make every effort to help service users take up further education or training for employment, starting with information in the welcome pack and being maintained through key worker sessions. They also support service users to manage their finances. They supply information about the local community and help service users to access this. Notes of a service users’ meeting showed that they are encouraged to vote. Within the home there is a variety of entertainment offered including access to television and videos and to a computer. The home also support service users to go on holiday either singly or with other service users, and this includes trips abroad as well as in England. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 11 Service users are encouraged and supported to keep links with families and friends and records showed that staff help service users to look at issues to do with relationships. They are able to have visitors, within certain restrictions that were agreed with the service users. They are also enabled to be as independent as possible, again with some restrictions because of communal living which are highlighted in the service users’ guide. As before there is a good balance between helping service users to be independent in food preparation and supplying them with a nutritious diet. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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 this service. Service users have good individual support. Their health needs are met and they are protected by policies and procedures for dealing with medication, although some training may be needed about individual medications. EVIDENCE: Hands-on personal care is not an issue at the moment with this service user group and so could not be properly checked. However a service user attested to how good staff are in his opinion, and individual support is facilitated by a good key worker system. Files showed that service users are provided with good support to access health professionals as needed, and their health is well monitored. There is close liaison with local multi-disciplinary and mental health teams. There are procedures for dealing with medication that are basically good, safe and well administered. However there are not photos of service users available with the Medication Administration chart. Also a staff member who had administered medication that day was not knowledgeable about some of the medication she had administered. At the moment there are no service Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 13 users who administer their own medication but this has happened in the past and there are policy and procedures to facilitate this. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All appropriate actions have been taken to enable service users to complain if they wish. The home has also worked appropriately to safeguard service users both in the home and in the community. EVIDENCE: The home has an up-to-date complaints policy and procedure which contains all necessary information. There have been no complaints since the last inspection and the Commission has received no complaints about the service. The home also has policies and procedures for safeguarding vulnerable adults and works together with Southwark Social Services to ensure that all staff have up-to-date training in this area. The manager also described pro-active work that they do with service users to try and ensure that they are not abused in the community. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from good provision of both personal and private space. EVIDENCE: The home is comfortable, homely and clean, and is well furnished. Spacious bed-sits promote independence; each has a wc and shower facilities to provide maximum personal privacy. The home has a communal lounge/dining room, a smaller room for quiet time and smoking, a large communal secured garden and medium size kitchen. All parts of the home are wheelchair accessible. At the present time there were no maintenance problems apparent. However staff reported frustration at the time taken to access maintenance when needed. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a well-trained, supervised and motivated staff group. EVIDENCE: Staff were seen to interact appropriately with service users, one of who said that staff were “very good, friendly and helpful”. The manager reported that about 90 of staff have an NVQ qualification, which is good and has been achieved partly by having a stable staff team. No new staff have been recruited since the last inspection over a year ago. The home’s recruitment practises could therefore not be checked. However the organisation has appropriate policies concerning recruitment. There is a good level of training led by the needs of service users and staff. There is a good supervision and appraisal programme which delivers regular supervision from staff. The deputy manager described good training that he had attended to fulfil his supervision role. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 17 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): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well managed home, where their views are sought. They are generally protected by the home’s health and safety procedures. EVIDENCE: The manager was seen to be “hands-on” and effective; she has now completed the NVQ4 in management. She is supported by a competent deputy. Service users have good input into the running of the home. As well as regular service users’ meetings they elect a representative who liaises with management on their behalf. Some service users also go to the Annual General Meeting of Equinox. The manager said that they have some input into the yearly development plan and their views are sought by three monthly questionnaires. To complete the quality assurance process the home needs to Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 18 send questionnaires to other stakeholders and complete and publish an annual report on the outcomes they find. Health and safety around the home was seen to be good, as were the monitoring checks seen. The exception to this was some hazardous chemicals which had been left in a toilet and the kitchen. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 19 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 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 20 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 YA6 Regulation 15(1) Requirement The registered person must ensure that all service users’ individual plans reflect changes and current need. Target date of 31/03/06 not met. The registered person must ensure that risk management strategies are in place where risk has been identified. Target date of 31/03/06 not met The registered person must ensure that staff are knowledgeable about the medication they administer and that service users photos are available when medication is administered. The registered person must ensure that a report about the home’s quality assurance monitoring is produced annually and supplied to the commission and to service users. The registered person must ensure that all substances hazardous to health are properly stored. DS0000007098.V329201.R01.S.doc Timescale for action 30/04/07 2. YA9 13(4)(b) 31/03/07 3. YA20 13(2) 31/03/07 4. YA39 24(2) 30/06/07 5. YA42 13(4)(c) 28/02/07 Southampton Way, 296/298 Version 5.2 Page 21 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. 3. Refer to Standard YA1 YA24 YA39 Good Practice Recommendations It is recommended that the Service User guide include a copy of the latest inspection report. It is recommended that there should be a planned maintenance programme. It is recommended that all stakeholders should be consulted as part of the home’s quality assurance process. Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Southampton Way, 296/298 DS0000007098.V329201.R01.S.doc Version 5.2 Page 23 - 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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