Inspection on 28/10/05 for The Village (58)

This inspection was carried out on 28th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Village (58) 21/04/05

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) 58 The Village Charlton London SE7 8UD Lead Inspector Ms Pauline Lambe Unannounced Inspection 09:20 28 October 2005 th The Village (58) DS0000036904.V259407.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 The Village (58) DS0000036904.V259407.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. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Village (58) Address 58 The Village Charlton London SE7 8UD 0208 854 8888 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) Greenwich Council Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2005 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 the residents when weather permits. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.75 hours. The service was last inspected on 21st April 2005. The inspection included talking to the one resident present, staff and management. It included a tour of the premises, inspection of records, care plans and safety systems. The inspector was able to observe staff interaction with the resident present during the day. Following the inspection comment cards were sent to relatives by the Commission to get their views of the service. At the time of writing this report these had not been returned and will be included in the next inspection report. Also following the inspection the Commission contacted senior management to discuss concerns regarding non-compliance with previous requirements and the need to improve the standard of decoration and hygiene in the home. What the service does well: What has improved since the last inspection? What they could do better: It was disappointing to note that some requirements made at the last inspection had not been met and little had been done to improve the environment. The registered person must ensure compliance with requirements made following inspections. Improvements were needed to ensure the safe management of medicines and the quality of care plans. The standard of decoration, maintenance and hygiene in the home must be improved. The registered person must provide a maintenance and The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 6 refurbishment programme with start and completion dates for work identified. The repairs noted under the environmental standards must be addressed. Senior management must ensure the home has a period stable management and that the new manager applies to register with the Commission. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Village (58) DS0000036904.V259407.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 The Village (58) DS0000036904.V259407.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): None Standards in this section were assessed at the last inspection. EVIDENCE: Standards in this section were assessed at the last inspection and the one requirement made had been met. No changes had been made to the systems in place. The Village (58) DS0000036904.V259407.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 and 7. The quality of care plans varied in how they reflected how assessed needs were to be met. Residents had limited ability to participate in risk taking and preferred lifestyles. EVIDENCE: Residents in the home could not verbally express their views on the service or comment on how involved they in making decisions about their lives. Only one resident was in the home during the inspection. From observation the resident seemed relaxed and staff displayed an understanding of how to communicate effectively with the resident. Two care plans were inspected. One included one risk assessment and provided some but not all the care plans needed to show how the resident’s needs were to be met. For example there was no risk assessment or care plan to show how the resident’s challenging behaviour would be managed. There was no date to show when care plans had been written. The second care plan was prepared to reflect changes the new manager introduced. This record included risk assessments and care plans to reflect The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 10 how the risks would be managed. The care plan was written in the first person and efforts had been made to involve the resident. Both care plans were prepared in word and ‘symwrite’ (pictorial) formats to help the residents to understand and agree with them. Neither care plans had a review date. Life plans were in place and had been prepared with the inclusion of the resident, relative, staff and life planner. Both life plans for due for review. Requirements 1 and 2. The Village (58) DS0000036904.V259407.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): 17 From the menus seen residents had a nutritious and varied diet provided. EVIDENCE: Most of the above standards were assessed as met at the last inspection. The new manager said she had changes planned as to how activities were managed and this will be assessed at the next inspection. The kitchen was clean and tidy. Fridge and freezer temperatures were recorded and a cleaning schedule was in place. Foods with a shelf life must be dated when opened and stored according to the manufacturers instructions. The home had no domestic staff employed therefore care staff did the cleaning, cooking and shopping. The menu was prepared with the involvement of the residents with the use of pictures. Meals provided were varied and nutritious. One evening a week residents had the choice of a take away meal, which staff said was very popular. Requirement 3. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 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): 19 and 20. Staff supported the residents to access healthcare services as needed and routinely. Improvements were needed to ensure medicines were safely managed. EVIDENCE: Most of the above standards were assessed as met at the last inspection. The exception to this being medicine management. All residents were registered with a local GP and were supported to access medical services. They were also supported to access routine NHS services such as dental, optical and chiropody services. One resident had recently spent a few weeks in hospital and staff, with the support of the relatives, ensured the resident had 24 hour support provided from the staff team. Also when the resident returned to the home waking night staff were on duty to ensure the resident’s needs were fully met. The home had a medicine policy and procedure. This was not dated and the new manager did not know when it was written. However the manager confirmed the procedures remained the same and the inspector agreed to get advice from the Commission pharmacist on the procedure in place to manage medicines for residents when the spend time away from the home. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 13 None of the residents could safely manage their own medicines. Medicines were safely stored in the sleep in room, which doubled as office space. Records were kept for medicines brought into the home but no record was kept for medicines returned to the chemist. Boots supplied the medicines in blister packs and printed administration charts. The administration records were well kept and no inaccuracies were noted. Internal and external medicines were stored together and there was some over stocking of medicines. The home had a small stock of homely remedies but did not have a policy agreed with the GP to administer these. No records were kept for receipt or administration of homely remedies. This issue was raised at the last inspection. Requirements 3 and 4. The Village (58) DS0000036904.V259407.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): None. EVIDENCE: These standards were assessed as met at the last inspection. No complaints or adult protection issues had been recorded in the home or referred to the Commission since the last inspection. The Village (58) DS0000036904.V259407.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, 26, 27, 28 and 30. The décor and environment looked tired and must be kept cleaner. Apart from painting one resident’s bedroom no improvements had been made to the environment since the last inspection. EVIDENCE: The home did not have a maintenance programme in place and virtually no redecoration or repairs had been done since the last inspection. Two bedrooms were inspected against the standards. One was nicely decorated and personalised. The other one needed work to bring it up to standard. The surface round the washbasin was cracked and damaged and no longer waterproof (this was identified at the last inspection), the window frame needed painting, one window did not have a restricted opening (this was identified at the last inspection) and the room was very impersonal. Other bedrooms viewed indicated attention was needed to hygiene and maintenance. In a second bedroom the surface round the washbasin was cracked and damaged and no longer waterproof, in another bedroom the door was not closing properly, the carpet was badly stained and the room was malodorous. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 16 There was no light in the passage outside two bedrooms on the first floor bedrooms (this was identified at the last inspection). Bedrooms varied in how much they had been personalised. The new manager said this was something she wanted the key workers to address. The bedrooms requiring attention were identified to the manager. The stairway walls needed repainting and repair to plaster cracks. The lounge was clean and tidy, bright and homely. The dining room would benefit from brightening up and repainting. The room continued to be used as a working area for staff. In the shower room on the top floor there was a large crack in the plaster at the top of the wall behind the WC. The cause of this must to be investigated and the damage repaired. The windowsill in the bathroom on the middle floor needed repainting and cleaning products were left in the room. Bars of soap were seen on the washbasins in the bath and shower rooms. Both the shower and bathroom needed attention to detail when being cleaned. Staff commented on the fact that they do not have enough time to clean the house properly and meet the residents’ needs. Requirements 6, 7 and 12 and recommendation 1. The Village (58) DS0000036904.V259407.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): 33, 34 and 35. Although employee personal files were not kept in the home there was information available to show recruitment procedures were followed. EVIDENCE: Staff rotas showed adequate staffing levels were maintained however staff felt that to provide care and manage the domestic chores additional hours may be needed. Staff also commented on the difficulties experienced through the lack of stable management in the home over a long period. A requirement made at the last inspection to ensure the rotas included the full name of staff on duty had not been met. Staff personal files were not kept in the home. To comply with regulation 17 the records listed in schedule 4 (6)(a-f) must be kept in the home and available for inspection. A record was available for each member of staff to show what information the employer had obtained. Therefore it was not possible to check whether gaps in employment had been explained or whether references were confirmed as being authentic. Staff training records were not kept up to date. However it was evident that training such as managing challenging behaviour, team building and moving & handling had been provided since the last inspection. There was also evidence to show that training was planned for topics such as introduction to autism, The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 18 epilepsy care, risk assessment and performance review. No fire safety or adult protection training had been provided since the last inspection and none was planned to take place in the near future. A number of staff had been in the home for some time and had a good awareness and knowledge of the residents needs. Requirements 8 and 9 and recommendation 2. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 19 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): 37,38,40 and 42. The home has had a number of acting managers over the past two years and this will have changed the ethos and day-to-day running of the home. Attention was generally given to providing a safe environment but a requirement made following the last inspection to fit a restrictor to one window on the top floor had not been met. EVIDENCE: Over the last two years the home has had a number of acting managers. Although efforts were made to maintain a stable staff team this has had an affect on the running of the home as each manager introduced changes. The current manager had been in post since July 2005 and confirmed verbally that she had the qualifications needed to run the home. In conversation with senior management following the inspection the commission was told that the plan is to keep this manager in the home and for her to apply for registration with the Commission. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 20 The home had policies and procedures however these must be reviewed to ensure they comply with current legislation, regulation and appendix 2 of the National Minimum Standards for Care Homes for Younger Adults. A selection of safety records were viewed. These showed that the last fire drill was held on 6/9/05. Other safety equipment and systems had been properly serviced. The electricity supply is due for inspection in December 2005. A requirement made at the last inspection to fit a restrictor to a bedroom on the top floor had not been met and this could pose a risk to the occupant of the room. Standard 39 was not assessed and therefore a requirement made at the last inspection was not reviewed. Requirements 10,11 and 12. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 21 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 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 2 2 X 2 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 2 2 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Village (58) Score X X 2 x Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x 2 x DS0000036904.V259407.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The Registered Person must ensure care needs are identified through assessment and are supported by a care plan showing how the need will be met. (Timescale of 29/08/05 was not met) The Registered Person must ensure resident care plans are kept under review. The Registered Person must ensure risks to the health and safety of residents are identified and as far as possible eliminated. Foods with a shelf life must be dated on opening and stored according to the manufacturers instructions. 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. (Timescale of 29/08/05 was not met) The Registered Person must ensure safe systems are in place to manage medicines. DS0000036904.V259407.R01.S.doc Timescale for action 05/12/05 2. 3 YA6 YA15 15 13 05/12/05 05/12/05 4 YA20 13 05/12/05 5 YA20 13 28/11/05 The Village (58) Version 5.0 Page 23 6 YA24 23 7 YA24 23 8 YA33 17 9 YA34 17 Records must be kept for all medicines returned to the chemist. Records must be kept for all medicines brought into the home and administered. This includes homely remedies. Internal and external medicines must be stored separately. Overstocking of medicines must be avoided. Medicine policies and procedures must be kept under review to ensure they reflect the current practice in the home. The Registered Person must ensure the premises are kept reasonably well decorated and well maintained. Repairs must be completed to the bedrooms as identified. Repairs and redecorating must be completed to the areas identified. The home must be kept clean at all times. The home must be kept free of offensive odours. Staff must be provided with liquid soap for hand washing. The Registered Person must ensure a maintenance and refurbishment programme is in place and a copy sent to the Commission. The programme must include start and completion dates for work identified. The Registered Person must ensure staff rotas include the full name and designation of all employees on duty at all times including agency staff. (Timescale of 29/08/05 was not met) The Registered Person must ensure the records listed in Schedule 4(6)(a-f) in relation to DS0000036904.V259407.R01.S.doc 05/12/05 19/12/05 05/12/05 05/12/05 The Village (58) Version 5.0 Page 24 10 YA37 9 11 YA39 26 12 YA42 13 each employee are kept in the home and available for inspection. The Registered Person must ensure the new manager submits a completed application to register with the Commission. The Registered Person must have in place a system to review, monitor and improve the quality of care provided in the home. (This requirement was not reviewed therefore the timescale of 29/08/05 remains unchanged) The Registered Person must ensure all windows above the ground floor have restricted openings. (Timescale of 29/08/05 was not met) 05/12/05 29/08/05 28/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA35 Good Practice Recommendations The Registered Person should consider having designated domestic staff to help raise the hygiene standard in the home. The Registered Person should ensure staff have regular update training on fire safety and adult protection. The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup 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. Extracts may not be used or reproduced without the express permission of CSCI The Village (58) DS0000036904.V259407.R01.S.doc Version 5.0 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. 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