Inspection on 23/02/06 for Sylvan Road (16)

This inspection was carried out on 23rd February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sylvan Road (16) 28/02/07

Sylvan Road (16) 13/09/05

Sylvan Road (16) 21/02/05

Sylvan Road (16) 14/09/04

Sylvan Road (16) 15/03/04

Sylvan Road (16) 08/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Sylvan Road (16) 16 Sylvan Road Wanstead London E11 1QM Lead Inspector Jackie Date Unannounced Inspection 23rd February 2006 02:00 Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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 Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sylvan Road (16) Address 16 Sylvan Road Wanstead London E11 1QM 020 8518 8004 020 8618 8004 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) Redbridge Community Housing Limited [RCHL] Miss Louise Elizabeth Prendergast Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 named people over 65 years. Date of last inspection 13th September 2005 Brief Description of the Service: Sylvan Road is a home for six people with mental health problems. It is one of a number of homes run by RCHL, Redbridge Community Housing Ltd. The house is in Wanstead in the London Borough of Redbridge. The ground floor has a bedroom with a shower, a lounge, dining area, kitchen and conservatory. The conservatory has a smoking and non-smoking sitting area and there is also a garden. Upstairs there are three single bedrooms, one double room and a bathroom. The home is near to bus stops and the train station. There are shops close by. Most of the residents have lived together for a long time. None of the residents go to regular day services but they do go to clubs and most of them can go out on their own and go where they want to go. The staff also organise some trips. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about three hours and took place during the afternoon. It was the second of the two inspections that each home must have during the inspection year. During the two visits all of the key standards have been checked. Staff and residents were spoken to. All of the communal rooms and two of the bedrooms were seen. Care and other records were checked. The main purpose of this visit was to monitor the progress of the requirements from the previous inspection. Feedback forms were left for staff and residents to give their comments on the service. What the service does well: What has improved since the last inspection? What they could do better: Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 6 There are three requirements from this inspection that are related to recruitment and staff records both of which are dealt with by the head office. The organisation has been addressing these requirements and they will be checked by a further visit to the head office. The other requirements are related to the building. Some areas need redecoration and the whole building needs a thorough deep clean so that the residents can live in a clean and comfortable home. Once this thorough clean has been done it should be much easier for the staff and residents to keep the home clean. 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. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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 Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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): These standards were not tested on this visit. However evidence from the last inspection was that information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the five standards. At the time of the last inspection standards two, three and four were tested and assessed as met. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs safely. Residents’ needs are reviewed regularly and care plans updated when needed. The care plans of the older residents are reviewed more regularly as a matter of good practice and this exceeds minimum standards. Residents are encouraged and supported to be involved in decisions about what they do and what happens in the home. EVIDENCE: Each resident has a detailed care plan which takes into consideration the personal, health care and social support needs of the residents. Each resident has a six monthly review with other professionals as part of the Care Programme Approach (CPA). Changes are made to care plans after these reviews if necessary. Residents are involved with these reviews and with writing their care plans. The care plans of residents over the age of 65 are reviewed monthly and this ensures that the staff team always have current information to work to. This good practice is to be commended and exceeds minimum standards. Risk assessments relevant to each individual are made. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 10 For example one person specifically has a risk assessment for using furniture polish. The risk assessments are reviewed regularly and updated when needed. Residents’ meetings are held each week and a variety of topics are discussed. This includes everyday things like the menu and shopping and also changes in the home and plans for the future. One of the residents’ bedrooms has recently been decorated and he said that he chose the colour. An independent advocate from the North East London Advocacy Service visits the home every six weeks to meet with the residents. This means that residents are given the opportunity to talk to an independent person about the home and about what they want to do. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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, 12, 13 & 14 Residents are encouraged and supported to do as much as possible for themselves and to be independent. Most residents go out when they want to and take part in a variety of activities and are part of the local community. EVIDENCE: Residents are encouraged to develop their skills. They participate in household tasks on a rota basis. This includes the cooking as well as domestic chores. One resident said that she had cleaned the kitchen cupboards that morning. Another resident cannot do as much as she used to but staff still encourage and support her to help around the house. For example they now spray the polish onto a cloth for her to use. Most of the residents are able to go out independently and can choose where they want to go. They are encouraged to do as much as they are able. For example some residents will go to the doctor on their own and also go to the bank to collect their money. Residents said that they go to the cinema, the pub, out for meals, to church and to concerts. They all go to clubs on Mondays and Saturdays and some of them go to church on Sunday. Therefore the residents have the opportunity to do what they wish and to be part of the local community. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 When required residents receive personal care that meets their individual needs and preferences. The staff team administer medication appropriately. Residents receive good support to ensure that they get the medical and health care that they need. This exceeds minimum standards. EVIDENCE: The residents are quite independent and require little support in terms of their personal care. The care plans contain details of the support needed. Some of the residents go to the doctor on their own and the staff support others. Residents are encouraged and supported to use community facilities. For example the dentist and the chiropodist. The practice of the optician visiting the home has now been stopped and residents will be using opticians in the community as recommended by the previous inspection. Records are kept of medical appointments and outcomes. One of the residents has a serious illness and the staff team monitors this person’s condition. He is supported by his mother and by his key worker to Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 13 attend appointments and discuss and decide on treatment. The health of another resident is deteriorating and the staff are monitoring this closely. Staff on duty were aware of the residents individual health needs and also of the action that the home had been taking to ensure that they received the health care that they need. The staff team are commended for the support that is given to residents in terms of their health care needs and this exceeds minimum standards. As previously stated the care plans of older residents are reviewed more regularly to identify any additional needs they may have because of the ageing process. Medication is stored in a locked cabinet in the office and is administered by the staff team. Medication records are up-to-date and have been properly completed. All medication is now administered directly from the containers provided by the pharmacist as required by the previous inspection. This ensures that the residents receive the correct medication Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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 There is a complaints procedure that would be followed in the event of any complaints being made. Staff are aware of issues of abuse and work to protect residents from abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. Residents said that they could talk to staff if they werent happy about things. As stated previously an independent advocate visits the home every six weeks and residents could talk to this person as well. There have not been any recorded complaints since the last inspection. The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff spoken to were aware of the issues of abuse and aware of their responsibility to residents. When residents go out the staff usually check where they are going and when they expect to be back. During the last inspection staff said that they know the usual pattern that each person has and if anything is different they will follow this up. All of the residents go to the bank or building society to sign for and withdraw their own cash. Some need support from the staff to do this. Records are kept of financial transactions. The organisation carries out annual financial audits. Therefore systems are in place to ensure that residents are protected from financial abuse. Some of the residents keep their own cash but cash is kept in the safe for others. As required by the previous inspection access to the safe has been tightened and the designated senior staff member on duty accesses residents’ monies. This person is also the designated key holder on Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 15 the shift. In addition cash is checked as part of the handover procedure and staff are required to sign that they have done this. Therefore any errors or discrepancies can be quickly identified and addressed. This provides added protection for both staff and residents and was a recommendation of the previous inspection. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29 and 30 Residents live in a home that is suitable for their needs. However, some redecoration and additional cleaning is needed to ensure that the home meets acceptable standards. EVIDENCE: The house is near to the local shops, bus routes and the tube station. The communal space consists of a lounge/diner, kitchen, conservatory, laundry room and a garden. The lounge diner is comfortable and has sky TV, video and a DVD player for the residents use. The conservatory has both smoking and no smoking areas and provides additional communal space and an area where residents can meet visitors in private if they want to. The two female residents share a large double bedroom and said that they were happy to do this. There are four single bedrooms. The ground floor bedroom has an ensuite shower. The inspector visited one of the upstairs bedrooms and the ground floor bedroom. The ground floor bedroom had just been redecorated and the resident using this room said that he had chosen the colours and was happy with the redecoration. At the time of the last inspection staff and residents had discussed and agreed areas that needed decorating during the coming year but no details of any further redecoration were available. Some redecoration is needed. For example cracks in the wall in the smoking room have been plastered but not redecorated. The need for some internal Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 17 redecoration was also identified as part of the monthly responsible person visits. All areas of the care home must be reasonably decorated to ensure that the residents live in a home that is of a satisfactory standard. In addition to the ensuite facility there is a bathroom on the first floor and three toilets around the home. None of the residents need any special aids and bathing and toilet facilities meet their needs. During a tour of the building it was apparent that several areas were not clean enough. For example the carpets in the hall, lounge and at least one of the bedrooms were stained. Skirting boards were dirty, toilet floors, walls and areas around the hand basin were not adequately cleaned. The need for more thorough cleaning had also been identified as part of the responsible persons monthly visits and is an immediate result of this the fridge/freezer had been pulled out and the floor and wall cleaned. The residents are involved in keeping the house tidy and clean and this needs to continue. However systems need to be in place to ensure that all parts of the home are clean and hygienic. The home does need a thorough deep clean and this needs to be arranged. It is recommended that a deep clean be arranged periodically to ensure that the level of cleanliness is satisfactory. Residents can then continue to do the day-to-day cleaning with support from the staff team. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 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 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): 33 and 34 The introduction of regular staff meetings will give the staff team opportunities to collectively discuss the service provided to residents. The organisation has taken action to address concerns about the robustness of recruitment practice and this will be tested via a further inspection of recruitment files at the organisations head office. EVIDENCE: At the time of the last inspection there had not been a staff meeting for several months and this was because it was difficult to arrange the meetings and to get everyone to attend. Staff meetings are now being held, as required by the previous inspection, and the next one was arranged for a few days after the inspection. Staff on duty confirmed that they are kept up-to-date on what has been discussed at meetings if they are unable to attend. They also said that they are looking at making changes to when meetings are held so that even if staff cannot attend every meeting they can at least attend alternate meetings. This will ensure that staff have an opportunity together to discuss issues, concerns and the development of the service. During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required checks on staff could be demonstrated to have taken place. This was discussed with the Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 19 organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office will take place to confirm that all of the necessary action has been taken and that the recruitment procedure is robust. The requirements with regard to recruitment will remain until this visit has taken place. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 20 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, 41 & 42 Appropriate arrangements have been put in place for the management of the home during the absence of the registered manager. The home provides a safe environment for the residents. The organisation has taken action to address concerns about staff records and this will be tested via a further inspection of recruitment files at the organisations head office. EVIDENCE: At the of the inspection the registered manager had just been seconded for three months to another home run by the organisation. Since then the senior support worker has been appointed as acting manager during this period. This arrangement will provide continuity and support to both staff and residents. During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required staff records were Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 21 maintained. This was discussed with the organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office will take place to confirm that all of the necessary action has been taken and that the necessary records are kept. The requirements with regard to records will remain until this visit has taken place. All of the necessary health and safety checks are carried out and records are kept of these checks. A safe environment is provided for the residents. Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 22 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 X 2 X 3 X 4 X 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 2 25 X 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X X X 2 3 X Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 23 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 3 4. Standard YA30 YA30 YA30 YA34 Regulation 23 23 23 19 Requirement All areas of the care home must be reasonably decorated All parts of the home must be kept clean. A thorough deep clean must be carried out. The registered persons are required to ensure that their recruitment procedure is robust and in line with regulation. The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For new staff before appointment. The registered persons are required to maintain records for the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For existing staff. Timescale for action 30/09/06 30/04/06 30/04/06 30/03/06 5. YA41 17 30/03/06 6. YA41 17 30/03/06 Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 24 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 YA30 It is recommended that deep cleaning is carried out on a regular basis Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 25 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 Sylvan Road (16) DS0000025929.V284494.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!