This inspection was carried out on 27th June 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
26 Therapia Road East Dulwich London SE22 0SE Lead Inspector
Lisa Wilde Unannounced 27 June 2005, 10:00am 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. 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service 26 Therapia Road Address East Dulwich, London, SE22 0SE 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 8946 2686 Odyssey Care Solutions for Today Lu Helen Cope CRH Care Home PC Care Home Only 5 Category(ies) of LD Learning Disabiltiy registration, with number PD Physical Disability of places SI Sensor Impairment 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14 December 2004 Brief Description of the Service: The home is located in a residential area of East Dulwich, close to public transport routes and local shops, cafes, pubs and a Post Office. The property is a large semi-detached house with a large garden and patio area to the rear of the house. The home provides care for five people with learning disabilities who have shared the home for several years. The current service users are aged between 35 and 42 years of age. There were no vacancies at the time of the Inspection. The vision statement of Odyssey is to work towards:“ A society where a learning disability is not a barrier to somebody’s perceived value or ability to make a meaningful contribution” 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day in June 2005 when the manager was not present at the home. The inspection took place with one member of staff and one service user as everyone else was out of the home. The inspection was quite brief given that the member of staff needed to be available to support the service user. The inspector tried to telephone the service manager following the inspection but as she was sick for a while the draft of the report was written without a manager’s comments being included. An agreement was made with the manager after the draft report was sent out that the second inspection of the service would take place soon in order for the manager to be involved and further discussion to be held about the issues raised during this inspection. What the service does well: What has improved since the last inspection? What they could do better:
The Service User Guide is not in a language or format that could be understood by the service user group at this home and it does not include some of the areas required by the standard meaning that service users and their families are not provided with all the information they need to make an informed choice about where to live and whether they are being offered everything that they should be. Some service users needs are not being met, regardless of the care plans that are in place as there is an ongoing issue of violence and aggression within the
26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 6 home. Service users are being placed at risk of harm and abuse. Service users are not supported by an effective staff team as there are not enough staff available consistently to fully protect service users from harm by other service users. Although generally the home is currently maintained to a reasonable level there is an ongoing issue with getting repairs and decoration done quickly at this home. 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. 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 The Service User Guide is not in a language or form that could be understood by the service user group at this home and it does not include some of the areas required by the standard meaning that service users and their families are not provided with all the information they need to make an informed choice about where to live and whether they are being offered everything that they should be. EVIDENCE: Most of the current service users at this home are non-verbal and cannot read or write; however, the home is registered for learning disabilities and it is possible to draw up a service user guide in a language and format that could be understood by some people from those groups who may wish to use this home e.g. by using pictures, video and language that is more simple. (See Requirement 1) The Service User Guide does not cover the required areas of the numbers of places provided; the relevant qualifications and experience of the staff; key contract issues of occupancy and termination; fees charged, what they cover and fees for any ‘extras’; service users’ (or their families’) views of the home and a copy of the complaints procedure and information about how to contact the local CSCI office and local health and social services. (See Requirement 2) 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 Service users’ needs are assessed and care plans are in place to identify how staff will support service users to meet those needs. Some service users’ needs are not being met, regardless of the care plans that are in place as there is an ongoing issue of violence and aggression within the home. Service users are being placed at risk of harm and abuse. EVIDENCE: The inspector saw evidence in two of the service user files that issues are identified and action plans drawn up in care plans to meet their needs. Reviews take place as required although minutes from one recent review that staff said had taken place were not on file. There is issue with two service users that has been ongoing for over a year now. One service user is frequently aggressive and violent with another service user and recently they have become aggressive at their day centre which has meant that they have been excluded from the centre for a period of time. Minutes of meetings held over the previous year show that concerns have been raised over this placement by the manager of the service, the service users’ advocate and other professionals yet there appeared to be little progress on the issue. Incident reports sent to the Commission have highlighted that there does not appear to be enough staff at the service to support all the service users and monitor their behaviour to prevent these violent acts taking place.
26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 10 The service user who is the focus of this aggression has said that they want to leave the service. Staffing levels appear to have been reduced since the last inspection in the light of meeting minutes stating that the levels of staffing previously had not been high enough to meet service user need. Requirements are made under this standard which also relate to Standards 23 & 33. (See Requirements 3 & 4) 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 standard(s) X These standards were not assessed at this inspection. EVIDENCE: 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 standard(s) 19 & 20 Service users’ physical and emotional needs are being met (apart from the issue identified above) by staff holding a thorough understanding of their healthcare needs and linking in with local services such as GPs, hospitals and clinics for additional support. Service users at this home are not able to self medicate but the home’s procedures are being operated effectively and service users are protected by the management and administration of medication. EVIDENCE: The member of staff on duty talked in detail through all the service users’ current healthcare needs and showed a thorough understanding of those needs and how the staff team works to meet them. Evidence from the files showed that contact with external professionals is made appropriately and service users are supported to attend regular appointments. The medication stocks, records and policies were examined and all systems were operating effectively and no errors or problems were noted. 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 13 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) 23 All service users are not protected from harm at this home as there is an ongoing issue of management of violence and aggression which has led to one service user being at risk of unwanted physical contact on a regular basis. EVIDENCE: Given the previous issue of one service user being placed at constant risk of harm from another service user it is evident that service users are being placed at risk of abuse. Requirements have been made with regard to this issue in previous standards. 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 14 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 & 30 Generally the home is clean, comfortable and safe with adequate and appropriate furniture and decoration in the communal areas. EVIDENCE: The home is located in a residential street and is generally comfortable and clean. The home is sited close to local amenities public transport and relevant support services. The furnishings, fittings and adaptations are satisfactory and generally suitable for the service users who live at the home. Southwark council who own the building maintains the premises. The previous inspector had been told it can take a considerable length of time for the home to get repairs completed once they have reported them to the appropriate department and staff confirmed that this is till the case. The need for repairs to be completed within a reasonable time scale is the subject of a previous requirement that is ongoing. (See Requirement 5) The sofas in the dining area are worn and dirty. (See Requirement 6) 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 15 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) 33 Service users are not supported by an effective staff team as there are not enough staff available consistently to fully protect service users from harm by other service users. EVIDENCE: As discussed previously the home cannot evidence that staffing levels are sufficient to effectively meet the needs of the service users and protect them from harm. Requirements relating to this standard have been made under other standards. 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 16 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) X These standards were not assessed at this inspection. EVIDENCE: 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 17 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 2 x x x x Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 x x x x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
26 Therapia Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 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 YA1 Regulation 5 Requirement The Registered Individuals must ensure that the Service User Guide is drawn up in a format that can be understood by more people from the service user groups for which the home is registered i.e learning disabilities. The Registered Individuals must ensure that the Service User Guide covers all areas required by Regulation 5 and Standard 1. The Registered Individuals must ensure that there are sufficient staff on duty at the home at all times to protect service users from risk of abuse/violence from other service users. The Registered Individuals must ensure that a review of staffing levels takes place and is sent to the Commission that outlines why staffing was reduced and why current levels are deemed appropriate in the light of incidents at the home. The Registered Provider must ensure that all repairs to the premises are completed within reasonable timescales. Unmet requirement: Previous timescale Timescale for action 28/02/06 2. YA1 5 28/02/06 3. YA6, YA23 & YA33 18 (1) (a) 13 (6) 31/08/05 4. YA6, YA23 & YA33 18 (1) (a) 13 (6) 30/09/05 5. YA24 23 (2) (b) 30/11/05 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 19 28/02/05 6. YA24 23 (2) (h) The Registered Manager must ensure that the dining room chairs are cleaned and made good or replaced. 31/12/05 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. Refer to Standard Good Practice Recommendations 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 46 Loman Street Southwark London SE1 0EH 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 26 Therapia Road G52-G02 S60225 Therapia Road V223763 270605 Stage 4.doc Version 1.40 Page 21 - 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!
