Inspection on 28/11/05 for Southview Close

This inspection was carried out on 28th 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 but made no statutory requirements on the home.

Other inspections for this house

Southview Close 20/06/06

Southview Close 17/05/05

Southview Close 04/10/04

Southview Close 13/05/04

Southview Close 15/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 Southview Close 1 Southview Close Rectory Lane Tooting London SW17 9TU Lead Inspector Davina McLaverty Unannounced Inspection 28th November 2005 08:15 Southview Close DS0000010226.V266243.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 Southview Close DS0000010226.V266243.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. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southview Close Address 1 Southview Close Rectory Lane Tooting London SW17 9TU 020 8682 3312 020 8682 3422 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.macintyrecharity.org MacIntyre Care Miss Vivienne Zoe Donald Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (3), Physical disability (12), of places Physical disability over 65 years of age (2) Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17TH May 2005 Brief Description of the Service: Southview Close is a home for twelve adults with learning disabilties , some of whom also have a physical disabilty. The property is purpose built and has been adapted for use by service users with wheelchairs. The home is on two floors and is divided into four flats, each with their own kitchen /dining room, lounge, toilet and bathroom. All bedrooms are single occupancy, with four bedrooms having ensuite facilties. Shared facilties include the garden. The home is situated in a quiet residential area near Amen Corner, Tooting and is within easy reach of shops and community facilties. The area is well served by public transport and the home has the use of an adapted minibus,. The home has six allocated parking spces. Street parking is restricted. Further information concerning the service can be found on the organisations website at www.macintyre-care.org. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was completed in one day starting at 8.15. The inspector met seven of the eleven residents. There is currently one vacancy. Communication with the majority of residents was difficult due to the level of their learning disability and many being non- verbal. The inspection consisted of the examination of records and an inspection of the communal areas of the home. The inspector spoke with the manager, four staff, and the care services manager who visited the home during the inspection. Residents seen were all appropriately dressed, relaxed and appeared very much at home. What the service does well: What has improved since the last inspection? At the last inspection, seven requirements were made of which four had been fully addressed and three were partly addressed. The recording systems have improved, allowing easier access to information, Recruitment of staff has led to a more stable staff team, which offers continuity of care to residents. Staff spoken with were more relaxed in their roles now that the home is registered as one care home and that they may be asked to work in any of the four units. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 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. Southview Close DS0000010226.V266243.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 Southview Close DS0000010226.V266243.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): 5 Contracts are available which sets out the terms and conditions with the home. EVIDENCE: The manager stated that she had obtained copies of resident’s placement agreements, which was now on their individual file. A copy was seen on the files examined. A contract between the resident and the home was also seen. This contract details the terms and conditions between the home and the resident. Southview Close DS0000010226.V266243.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 plans and monthly summaries are in place. The care planning system is person centred and aims to ensure that individual needs are being met. Risk assessments must be in place for all residents and updated to ensure residents health and welfare. EVIDENCE: Two care plans were examined at this inspection. The home uses a person centred plan, which is specific to resident’s individual needs. The manager stated that work on care plans is on going. One of the files looked at was for a resident who moved in six weeks ago. Although no care plan was yet in place guidelines were available and one of the staff spoken with was clear as to the information to be included in his plan. Consultation with the residents relative would take place, as the staff acknowledged how valuable the relatives view was, particularly as this person had been caring for their relative since his birth. The other care plan examined contained a personal profile and several photographs. The plan tried to reflect the needs, aspirations and goals of the individual and sets out how to make them a reality. Evidence of the resident’s involvement was seen. The manager stated that pictures are used where Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 10 residents are not able to communicate verbally. Guidelines were available detailing the resident’s daily routines. These guidelines enable new staff to understand how to deliver care to residents. An in house review was seen to have taken place. Risk assessments for the residents was examined, but for one of the residents none was available. This must be rectified, it was unclear why risk assessments for the residents whose file was examined was not in place. The manager stated that the majority of assessments had been updated and was ongoing. However, consideration must be given to reviewing the current system to ensure all risk assessments are in place. The home has a missing persons policy and staff are clear as to the action required in the event of a resident being absent. Southview Close DS0000010226.V266243.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): 11,13 & 15 Residents participate in activities in the home and the community. Residents are encouraged and supported to maintain contact with their family and friends. Staff encourage residents to be as independent as possible. EVIDENCE: Staff support and provide opportunities to residents to develop social, emotional, communication and independent living skills. Currently residents who are able are involved in domestic and household chores. Staff reported that they have had training in Makaton and the staff team as a group are always looking at how they can improve communication with residents, particularly those residents who reside on the ground floor, where the majority could not communicate verbally. The home has its own mini bus, which allows trips further a field to be planned for the weekends. The bus enables staff to be spontaneous and take service users out with minimum planning. The manager reported that the home should be getting a new minibus next year, which will better meet the need of residents with less mobility. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 12 The senior support worker stated that the majority of the residents attend local day centres five days a week. However, a couple of residents attend part of the week and have one to one support, or attend classes at an adult education centre or participate in projects such as theatre and gardening. Two of the older residents do not attend regular day care, staff will take them out or involve them in- house activities e.g. puzzles, games, TV or listening to music. One of these residents will go out to a local Asian luncheon club, which he appears to enjoy. Some residents attend evening clubs. Staff stated that regular trips take place to the cinema, shopping, and parks and out for meals or to the pub. Evidence of these trips was seen in the care plans examined. One resident who also has a mental health disorder currently has one to one support for most of the week and this resident is involved in a variety of activities. A variation to the categories of registration must be submitted to the Commission. Residents have contacts with their families, which vary from day/weekends at home to relative visits to the home. Staff support as necessary. Staff reported that they also accompany residents on holiday, if they wish to go. All residents are encouraged to go on holidays. Southview Close DS0000010226.V266243.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): 20 Appropriate systems are in place, in respect of the administration of medication which ensures individuals well being. EVIDENCE: The home has an adequate medication policy which all staff are expected to read and familiarise themselves with. In discussion with a senior staff member, the inspector was informed that all staff must receive training from Boots and staff within the home before they are to administer medication. Medication is always checked when it is delivered and signed as correct on the Medication Administration Record (MAR) sheets. No resident is able to self-administer his or her own medication. Staff sign when medication is given. No errors were seen in the MAR sheet examined in Flat C. A locked fridge is used to store any medication, which requires refrigeration. The home has access to the local pharmacist who dispenses and delivers medication to the home. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 An appropriate written complaint procedure is available, as well as a pictorial one, which is displayed on notice boards in the various units. Organisational policies and procedures are in place to protect residents from abuse. EVIDENCE: The complaint procedure continues to be evident in the home. The upstairs complaints book was seen and one complaint had been raised by a resident, which had been appropriately responded to. The home must ensure that documentation, which refers to the National Care Standards Commission, is amended to reflect the Commissions new name. Three staff spoken to were aware of the Protection of Vulnerable adults procedures as well as whistle blowing. A copy of Wandsworth Protecting Vulnerable Adults Procedure was seen in the home. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 & 30 The standard of accommodation is generally adequate providing residents with a comfortable and homely place to live. The home was seen to be clean and hygienic. EVIDENCE: The home is divided into four units, two on each floor. All four units, which are quite different, were homely (particularly flats C and D) in appearance taking into account resident’s individual needs. Decorating has been identified in the homes development plan to be addressed in the forthcoming year. Decorating is an on –going issue in particular on the ground floor where the residents are more challenging. As stated above the home is divided into 4 units each with their own kitchens, lounges and laundry rooms. Specialist equipments e.g. hoists, raised toilet seats and Zimmer frames are available to individual residents as required. Requirements, concerning redecoration made at the last inspection are still outstanding but the manager stated that they were in hand e.g. the redecoration of the laundry rooms and would take place early next year. The requirement made at the previous inspection remains, as the work has not been addressed. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 16 A large garden is available and consideration is being given to landscaping it to best meet the needs of the residents. The home was seen to be clean on the day of the inspection. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 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): 34 The organisation has a comprehensive recruitment policy and procedures, which should protect residents from harm. EVIDENCE: The inspector was unable to examine staff records as they are kept at the organisations other registered care home where the main office is located. The manager must ensure that she obtains written confirmation that the full recruitment policy has been used and confirmation receive that references, health declaration and Criminal Bureaus checks have been carried out for all staff working in the home. The manager stated that all staff now have ID badges which they must wear when out with residents. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 18 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 The home is well managed with opportunities for residents, where able, to voice their views on how they would like the home to run. Resident’s health and safety is promoted by policies, practices and recording systems at the home. EVIDENCE: Discussion with the Registered Manager indicated that she has a clear understanding of the strengths and needs of the residents and staff in the home. Staff described the manager as being receptive to new ideas, being available and being a good listener. The area manager for the organisation visited the home during the inspection. The manager stated that part of his visit was to support staff dealing with the sudden death of a resident. The area manager visits monthly and will speak to residents and staff, examines records and sends a copy of his report to the Commission. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 19 Clear Health and Safety policies, procedures and recording systems are in place at home. Records seen included hot water tests, fridge and freezer temperature records and electrical items in the home. The fire policy is displayed in the home. The fire alarm system is tested weekly and fire drills carried out regularly. However, the inspector noted that following the testing of the alarms one of the doors is not closing properly which has been occurring for several weeks. Fire maintenance staff visited during the inspection and stated that the failure of the door to close properly was due to the hinges on the door needing adjustment. The manager said that she would contact the Housing Association to address. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 20 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 x x x 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 3 3 LIFESTYLES Standard No Score 11 3 12 x 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southview Close Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 2 x DS0000010226.V266243.R01.S.doc Version 5.0 Page 21 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 2 Standard Care Standards Act 9 Regulation 12(1) 13.4 Requirement A request for a variation to the category of registration must be submitted. The Registered Persons must ensure that risk assessments for all residents are in place and that they are regularly updated. (Timescale of the 30/8/05 not fully met) The Registered Person must ensure that all documentations regarding complaints refer to the Commission For Social Care Inspection. The Registered Person must ensure that redecoration of the laundry room’s takes place. (Timescale of the 30/08/06 not met) The Registered Persons must ensure that details of checks carried out on staff (with dates) are available in the home. (Timescale of the 30/07/05 not met) The Registered Persons must ensure that the fire doors can fully close. Timescale for action 31/01/06 31/01/06 3 22 22 (7) 31/01/06 4 24 23(b) 31/01/06 5 34 17(2) Sch2 & 4 31/01/06 6 42 23(4) 31/01/06 Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 22 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 1 Good Practice Recommendations The Registered person should ensure that only currents documents, which refer to the entire home, are displayed in the foyers and on notice boards. Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 23 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 Southview Close DS0000010226.V266243.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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