Inspection on 21/04/05 for The Village (58)

This inspection was carried out on 21st April 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

The Village (58) 28/10/05

The Village (58) 09/11/04

The Village (58) 10/05/04

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 The Village 58 the Village Charlton London SE7 8HD Lead Inspector Pauline Lambe Announced 21st April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Village Version 1.10 Page 3 SERVICE INFORMATION Name of service The Village Address 58 The Village Charlton London SE7 8HD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8856 9322 London Borough Greenwich Vacant CRH 6 Category(ies) of LD 6 registration, with number of places The Village Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 9/11/04 Brief Description of the Service: The Village is a detached Victorian house situated in a residential area close to Charlton village and the main centres of Woolwich and Greenwich. The home is part of a group of homes providing care for six residents with learning disability. The London Borough of Greenwich Social Services Department provides the care and the property is owned and maintained by Hyde Housing. The home has six single bedrooms for service users and the accommodation is arranged over three floors. A lift provides access between the ground and first floor and stairs between the first and second floor. One bedroom is located on the ground floor, which is wheelchair accessible. This bedroom has an ensuite shower and toilet and the room is suitable for a resident with a physical or mobility disability or is a designated wheelchair user. On the ground floor there is a communal dining room, a kitchen, a lounge and a laundry room. Toilets and bathing facilities are provided on all floors and all bedrooms have wash hand basins. There are garden areas to the rear and side of the house, which is wheelchair accessible, includes a large patio area and a small lawn. The garden area is attractive and secluded and is much enjoyed by service users when weather permits. The Village Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Please note that due to an administration error in the Commission office the provider did not receive a copy of this report by the target date, which is within 28days of the inspection. The error was not discovered until July and a draft copy of the report was sent to the provider on 28th July 2005. The dates for compliance with requirements and recommendations have been changed to compensate for the time loss. The Commission apologise for any inconvenience caused to residents, relatives or the provider. This unannounced inspection took place over 5 hours and was carried out as part of the statutory inspection programme. The inspection included talking to residents, a tour of the premises, inspection of records, care plans and safety systems. The inspector was able to observe staff interaction with four residents present during the day. The inspector spoke with some of the staff team, the manager and assistant manager. The befriender of one resident did speak to the inspector and did not raise any concerns with the service. Three staff spoke to the inspector and were positive about their role and management support. Some relatives were contacted by phone after the inspection to get their views of the service. Feedback from relatives about the service was positive. What the service does well: What has improved since the last inspection? What they could do better: The standard of decoration in the home could be improved. This did not pose a risk to residents but would make the environment more pleasing. The registered person should give more attention to having a routine maintenance and refurbishment programme in place. Rooms must always be clean and adequately decorated prior to the admission of a new resident as this had not always been the case. The Village Version 1.10 Page 6 The system in place to review the quality of the service provided must be improved. Staff must prepare a care plan for all resident’s identified care needs. Management must ensure hot water temperatures are maintained close to 43C degrees. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Village Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection The Village Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 and 5. The home provided adequate information for residents and others to make a decision as to its suitability. Admission procedures ensured residents and their representatives were fully involved in the process. EVIDENCE: The home had a Statement of Purpose and Service User guide to comply with regulation. Residents had individual contracts for service. New residents had the opportunity to visit the home and have overnight stays prior to deciding on admission. One resident had been admitted since the last inspection. From evidence provided the admission process was well managed. Sadly the room was not well prepared for the resident prior to admission. The room was bare, holes in the walls had been roughly filled in, the room needed repainting, the net curtains needed a wash and the washbasin surface needed replacing. Requirement 1. The Village Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 and 10. Staff displayed an awareness of resident needs and their ability to understand resident preferences. They took into account the resident’s ability when endeavouring to involve them in discussions about their care and lifestyle. EVIDENCE: It was not practical to obtain residents views verbally as to how involved they were with decisions made about their lives. From observation residents seemed relaxed and staff displayed an understanding of how to communicate and read residents individual method of communication. Relatives and representatives seen or contacted said they were satisfied with the care provided and the amount of involvement they had in decisions made about their resident. Two care plans were inspected. These included risk assessments and assessment of need. Care plans did not provide adequate information as to how assessed needs were to be met. Care plans were kept under review. Life plans were in place and had been prepared with the inclusion of the resident, relative, staff and life planner. Resident records were respectfully written and safely stored. Requirement 2. The Village Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17. From the evidence available management and staff endeavoured to ensure the residents enjoyed an inclusive and active lifestyle. EVIDENCE: All residents attended day centres where they had opportunities to develop skills to suit their individual ability. Staff supported residents to participate with the community through outings to shops, cinemas, pub and restaurants. All residents were registered to vote. Staff arranged day trips, local outings and holidays. They also arranged inhouse activities such as parties, video evenings and bar-b-ques and invited resident’s relatives to attend. Resident’s activities and commitments were included on the staff duty rota. At weekends residents got up at their leisure and were supported to relax and enjoy their time off and to use local facilities of their choice. Menus seen and food stocks indicated a varied and balanced diet was provided. Relatives said they were satisfied with the quality of meals provided. The manager agreed to get advice from the Environmental Health Department as to whether fly screens should be fitted to the kitchen window. The Village Version 1.10 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 and 21. The health needs of the residents were met with evidence to support multi agency working. Staff had a good understanding of resident’s needs and how to communicate with them. Medication systems in place required monitoring to ensure safe practice. EVIDENCE: As mentioned residents were unable to verbally advise the inspector on their perspective of the service. Staff said they got to know the resident preferences. From observation staff communicated with residents appropriately to try to involve them with choice and decision-making. Residents were registered with a local G.P and evidence was seen of involvement with other relevant professionals. None of the residents managed their own medications. Medication systems required improving. Policies and procedures were out of date, there was confusion about the use and stock of homely remedies and many medications had not been signed for at the time of administration. This was not considered safe practice. The inspector was told that death and dying would be managed on an individual basis. The manager said residents would be welcome to remain in the home for as long as their care needs could be met. Requirement 3. The Village Version 1.10 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home had systems in place to ensure the safety of residents and to manage complaints made about the service. EVIDENCE: Relatives told the inspector that if they had a concern they would happily discuss it with the manager or a member of staff. Staff said they felt they had the ability to recognise if a resident was unhappy or concerned. The home had a complaints and adult protection procedure in place. In the event of an allegation or suspicion of abuse the home implemented Greenwich Adult Protection procedures. It was recommended at the last inspection that a local policy be made available to staff to ensure they knew how to respond to an adult protection issue. This recommendation had not been acted upon and has been repeated in this report. Robust systems were in place to ensure safe management of resident’s personal money. No complaints had been made about the service to the home or the Commission since the last inspection. Recommendation 1. The Village Version 1.10 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 and 30. There had been no changes to the environment since the last inspection. The home provided a homely atmosphere for residents. Parts of the home would benefit from having a maintenance and refurbishment programme in place and from redecoration to improve the overall ambience. EVIDENCE: The home was generally clean and tidy. Hand washing facilities were provided together with protective clothing. Two bedrooms were inspected against the standards. One was satisfactory but the other one needed some work to bring it up to standard. This has been more fully referred to standard 5. Other bedrooms viewed were mainly nicely personalised to reflect the occupant’s interests. The stairway walls, lounge ceiling and bathroom needed repainting and repair to plaster cracks. The light outside two bedrooms on the first floor was not working and could pose a risk hazard to residents and others. The net curtains on most of the windows needed washing. A lift was provided between the ground and first floor. Apart from this residents did not require any other special equipment. Residents seemed pleased to return to the home from their various outings. Requirement 4 and recommendation 2. The Village Version 1.10 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,35 and 36. The home had a stable staff team with clearly defined roles. Staff expressed their satisfaction and confidence in the new management team in the home. EVIDENCE: Staff had job descriptions and were clear about their role within the home. The inspector was of the opinion that the staff worked together as a supportive team to ensure resident needs were met. Staff said they received training that enabled them to fulfil their role. Records showed staff received formal supervision. Eleven domestic hours a week was provided and this had improved the standard of hygiene in the home. The home operated a key worker system and staff spoke confidently and knowledgeable about the needs of their key residents. Staff rotas were kept and those given to the inspector for the period 28/2/05 to 27/3/05 showed the home was adequately staffed. A requirement made at the last inspection about the inadequacy of the information recorded on staff rotas had not been met. Regular staff meetings were held and minutes kept. Staff said they felt they had a voice at these meetings and were encouraged to make suggestions to improve the service. Relatives said staff kept them appropriately informed about their resident’s health and well being. Requirement 5. The Village Version 1.10 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,4 and 42. Since the last inspection a new manager and part time assistant manager were in post. Adequate systems were in place to ensure the safety of residents and others. EVIDENCE: A new manager was in post and said he was doing an NVQ 4 in care and management and the Registered Manager Award. He had fifteen years experience working with people with learning disability. A newly appointed part time assistant manager supported him in his role. The new manager must ensure his application to register with the Commission has been submitted. The manager said he returned quarterly figures to senior management in relation to supervision, accidents and health & safety. Annual questionnaires were sent to relatives and advocates asking their views of the service. However these audits were not collated or supported by an action plan to implement systems for improvement. Reports were sent to the Commission as required by regulation 26. The home had policies and procedures in place. These did not have a review date and some did not have an implementation date. The Village Version 1.10 Page 16 Records required by registration were kept. The home had a fire risk assessment and evacuation policy. A random selection of other safety records were inspected. In two of the bathing facilities there was a sign over the basins saying ‘very hot water’. Hot water outlets checked seemed to be within safe limits. The home did not have a thermometer to check this nor a system in place to monitor hot water outlets on a regular basis. One bedroom on the top floor did not have a restricted opening which could pose a risk to residents. Requirements 6 and 7. 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 The Village Score 2 3 3 Standard No 24 25 26 27 28 29 30 Version 1.10 Score 2 3 3 3 3 3 3 Page 17 9 10 LIFESTYLES 3 3 Score STAFFING Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 2 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 x 2 3 3 2 x The Village Version 1.10 Page 18 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 5 Regulation 23 Requirement The Registered Person must ensure the premises are maintained both internally and externally. Prior to admission of a new resident bedrooms must be clean and adequately decorated. The bedroom occupied by the last resident admitted must be redecorated. The Registered Person must ensure care needs identified through assessment are supported by a care plan showing how the need will be met. The Registered Person must ensure safe systems are in place to manage medications. The provision of homely remedies must be discussed and agreed with the G.P. Medications must be signed for at the time of administration and the policies and procedures must reflect the practice in the home. The Registered Person must ensure the premises are kept reasonably well decorated. The areas identified as needing attention must be addressed. Version 1.10 Timescale for action 29th August 2005. 2. 6 15 29th August 2005. 3. 20 13 29th August 2005. 4. 24 23 29th August 2005. The Village Page 19 5. 33 17 6. 39 26 7. 42 13 The Registered Person must ensure staff rotas include the full name and designation of all employees on duty at all times including agency staff. (Timesclae of 30th December 2004 was not met) The Registered Person must have in place a system to review, monitor and improve the quality of care provided in the home. The Registered Person must ensure hot water temperatures are monitored and maintained close to 43C degrees and all windows above the ground floor have restricted openings. 29th August 2005. 29th August 2005. 29th August 2005. 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 23 Good Practice Recommendations The Registered Person should consider introducing a local policy and procedure in relation to adult protection. The current procedure may cause delay in how staff manage such incidents. The Registered Person should ensure a maintenance and refurbishment programme is in place. 2. 24 The Village Version 1.10 Page 20 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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