Inspection on 02/11/05 for Southwood Gardens

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southwood Gardens 12/09/06

Southwood Gardens 30/06/05

Southwood Gardens 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 Southwood Gardens 2 Southwood Gardens Ilford Essex IG2 6VF Lead Inspector Ms Harina Morzeria Unannounced Inspection 02 November 2005 09:30 Southwood Gardens DS0000028454.V263543.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 Southwood Gardens DS0000028454.V263543.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. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Southwood Gardens Address 2 Southwood Gardens Ilford Essex IG2 6VF 020 8551 8497 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) southwoog@nor.co.uk Norwood Ravenswood East Ms Roberta Lynn Devitt Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Southwood Gardens is a registered care home for six younger adults with learning disabilities run by Norwood, a not for profit, Jewish organisation. It is situated in Barkingside, in the London Borough of Redbridge, close to a small local shopping area and other amenities. The house is divided into two selfcontained three-bedroom flats. The aim of the scheme is to offer a smallscale, family style environment which encourages maximum independence for the service users. All service users have their own bedrooms which are well furnished and decorated. One bedroom in each flat has an ensuite bathroom. Shower rooms are shared between the other two service users in each flat. Office and staff sleeping in accommodation is separate. There is a spacious well maintained garden at the side and rear of the house. Appropriate communal space is provided. The manager and staff support service users to maintain and develop independent living skills, attend college for various courses, as well as accessing community facilities locally and at the Leonard Steiner Centre (Jewish community centre) in Barkingside. Staff who have experience and skills to cope with these needs are employed in the home. Extensive training is provided organisationally to all the staff as part of their induction training, with ongoing training being provided as identified jointly by the staff and the manager. Personal care is provided on a 24-hour basis, and health care needs are met by staff supporting service users to attend appointments with health professionals. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Three requirements were set at the previous inspection and the registered person has yet to comply with these. These have been restated with new timescales for compliance. Further information about unmet requirements can be found in the relevant standard. The inspection was unannounced, starting at 9:30 a.m. and lasted for approximately 4 hours. The inspector spoke to three service users during the course of the morning, who were all able to express their views. A senior staff member was present during the visit. A sample of service users’ files were examined as well as the complaints record. What the service does well: The standard of the décor, furnishings and fittings is being improved with an ongoing refurbishment programme in place. This provides the service users with an attractive and comfortable place in which to live. The manager and staff support the service users to exercise choice and control over their lives in order to promote their independence. The routines of daily living and activities available are flexible and varied, to suit each persons expectations, preferences and capacities. The service users said that they are asked about issues that affect them in the home and are kept informed about any changes and events that take place. Regular service user meetings take place in order to facilitate this. All necessary health care services are accessed for service users in order to meet their assessed and specialist needs. Each service user has a daily programme of activities outlined in an activity chart. Hence, the service users are supported by staff to attend college, go shopping locally, go to the gym, attend courses at the local adult education centre, as well as attend activities at the Leonard Steiner centre. Evening activities include going to restaurants, pubs and cinema. Holidays are also arranged in consultation with the service users. Visiting times are flexible and visitors are welcome at any reasonable time. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The manager and the responsible individual for the service must ensure that the requirements from the previous inspections are addressed by the new timescale. The manager must ensure that all service users now receive contracts/ terms and conditions of occupancy. Additional staff to be recruited to provide extra cover during peak hours to provide support to the service users who have been assessed as requiring additional support as well as considering staffing levels when outings and activities have been planned during the daytime and evening. The organisation to implement a formal quality assurance system in order to continually monitor and review the development of the home, for service users’ benefit. Monthly monitoring visits must be carried out as required under Regulation 26, by the responsible individual, with copies of the report being forwarded to the CSCI, in order to demonstrate the internal quality monitoring of the service. Failure to comply by the revised timescales will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 7 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. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 8 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 Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 9 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,and 5 Prospective service users have the information they need in a Statement of Purpose and a Service Users Guide to help them make an informed choice about where to live. Service users must have an individual contract or a statement of terms and conditions with the home so that they are clearly aware of the service that the home states they will provide. Standards 2, 3 and 4 were not tested on this visit, however evidence from the last inspection was that: Prospective service users’ individual needs are assessed and they know that these will be met within the home they are accommodated in. New service users are given an opportunity to visit the home and stay there for a trial period, before they decide if they want to live there permanently. EVIDENCE: A comprehensive Statement of Purpose as well as a Service Users Guide are available, containing the information prospective service users and their representatives need to have, to make an informed choice about where to live. Upon discussion with the senior person present during the inspection, he informed the inspector that consultation with the service users continues to take place regarding the content of the contracts by advocates. However this is a slow and ongoing process due to service users limited capacity. However they hope that the process will be completed by the new timescale set, resulting in the requirement being met. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 10 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): 6,7,8,9 and10 Each service user has an individual care plan called individual person plan. This outlines the service users’ needs and personal goals. Service users are consulted about their likes and dislikes and are encouraged to make independent decisions as far as possible. Service users know that information about them is handled appropriately and their confidences are kept. Appropriate risk assessments are in place for activities undertaken by the service users in order to promote their independence. EVIDENCE: As stated above, each service user has an individual person plan, which outlines their individual needs and how these will be met. The inspector looked at the individual person plans for two service users living in the home and noted that each plan outlines the service user’s individual needs and how these are to be met by staff. Service users spoken to said that they are given choices and are supported by staff to do the activities that they choose. The service users spoken to confirmed that they attend a residents meeting each week and in fact on the day of the inspection, two of them were typing up the minutes of the meeting on the computer, as part of their activity programme. From viewing minutes of the previous residents meetings the inspector was satisfied that the service users are consulted about matters Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 11 affecting their daily lives and make valid contributions to these meetings. For example, discussions take place about outings, evening activities as well as future planning for holidays plus menus and any changes taking place within the home. As identified at the previous inspection, there are risk assessments in place for each service user. These identified risks for the service users and indicate ways in which the risks can be reduced to enable the service users’ needs to be met as safely as possible. The inspector was pleased to note the level to which one service user has been enabled to develop independence skills which allows him to lead a very independent lifestyle, for example he is able to travel on public transport, and go shopping and to the gym independently. The risk assessments for him are regularly reviewed and updated. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 12 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): These standards were not tested on this visit. However evidence from the last inspection was that: Service users have opportunities for personal development and are able to take part in age, peer and culturally appropriate activities. Service users are encouraged to engage in appropriate leisure activities within the local community, which are also culturally appropriate. Service users are supported to keep in contact with their relatives. Staff respect service users’ rights and their responsibilities are recognised in their daily lives. Service users are given meals that they like and that meet their needs and individual preferences. Culturally appropriate diets are catered for, for example, a kosher diet. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Southwood Gardens DS0000028454.V263543.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): These are standards were not tested on this visit. However evidence from the last inspection was that: Service users receive personal care in a way that meets their individual needs and preferences. The staff team support the service users to get the health care that they need. Medication is appropriately administered by staff who have been trained to do this. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Southwood Gardens DS0000028454.V263543.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): These are standards were not tested on this visit. However evidence from the last inspection was that: The complaints procedure is in a pictorial format to help service users understand how to complain. Staff are aware of issues of adult protection and the need to protect service users from abuse. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. However the complaints and concerns log was examined by the inspector. Since the last inspection, one of the service users alleged that she had been abused by a member of staff. This incident was promptly investigated by the manager, who implemented the organisations adult protection policies and procedures. Southwood Gardens DS0000028454.V263543.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): These are standards were not tested on this visit. However evidence from the last inspection was that: Service users live in a homely and comfortable environment. Bedrooms and communal areas are spacious, meet their needs and promote their independence. Toilets and bathrooms provide sufficient privacy. Shared spaces are spacious and sufficient spaces are available for the numbers of people living in both the flats. The home is clean and hygienic. EVIDENCE: The above standards were not specifically tested on this visit, and there were no outstanding requirements in relation to these standards. At the time of the last inspection, all of the outcome standards were assessed as met. These standards will be re-tested at a future inspection. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These are standards were not tested on this visit. However evidence from the last inspection was that: The organisation have a staff recruitment policy and procedure which is followed when new staff are recruited, ensuring the service users are protected by robust checks being carried out. All the staff have job descriptions which clearly outline their roles and responsibilities, ensuring that they understand the tasks required of them and can protect and promote the well-being of service users. Staff are competent and are trained to acquire sufficient skills and experience to carry out their tasks. Staffing levels are satisfactory although peak time staffing levels need to be monitored in order to ensure that sufficient staff are on duty to meet the individual assessed needs of the service users. staff receive appropriate training, supervision and support to carry out their tasks efficiently in order to meet the needs of the service users. EVIDENCE: Staffing levels are satisfactory although peak time staffing levels need to be monitored in order to ensure that sufficient staff are on duty to meet the individual assessed needs of the service users. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 Standards 37, 38 and 42 were inspected at the previous inspection and were met. Appropriate quality monitoring systems must be in place to ensure continuously review and development by the home. EVIDENCE: The above standards were not specifically tested on this visit, except standard 39. As is stated at the previous inspection, the organisation is required to implement a formal quality assurance and monitoring system based on seeking the views of service users, to measure success in achieving the aims and objectives of the home. The views of the service users’ family, friends and advocates must also be sought on how the home is achieving the goals for service users. The inspector remains concerned that monthly Regulation 26 visits are not being carried out by the responsible individual. This requirement has been repeated over the previous inspections and must be fully complied with, otherwise enforcement action will be taken by the Commission for Social Care Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 18 Inspection to secure compliance. These reports are necessary to demonstrate that the registered providers have in place satisfactory systems for monitoring the welfare and safety of service users and to ensure that the service is operating in accordance with the home’s aims and objectives and legal requirements. Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x X x 2 Standard No 22 23 Score 3 3 ENVIRONMENT Standard No 24 25 26 27 28 29 30 STAFFING Score INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 X X X X X X x LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southwood Gardens Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000028454.V263543.R01.S.doc Version 5.0 Page 20 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 5 Regulation 5 Requirement The registered person must provide each service user with a written and costed contract/ statement of terms and conditions between the home and the service user. Previous timescale of 31/09/05 not met. The registered person to ensure that an organizational formal quality monitoring system is in place and implemented to measure success in achieving the homes aims, objectives and Statement of Purpose. Previous timescale of 31/09/05 not met. The registered person must ensure that monthly monitoring visits are being carried out as is required by regulation and the report forwarded to the CSCI promptly. Previous timescale of 31/09/05 not met. Timescale for action 31/01/06 2 39 17/18 31/01/06 3 39 26 31/01/06 Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 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. Refer to Standard Good Practice Recommendations Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Southwood Gardens DS0000028454.V263543.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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