Inspection on 27/09/05 for Therapia Road, 26

This inspection was carried out on 27th September 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Therapia Road, 26 11/05/06

Therapia Road, 26 27/06/05

Therapia Road, 26 14/12/04

Therapia Road, 26 10/08/04

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 Therapia Road 26 Therapia Road East Dulwich London SE22 0SE Lead Inspector Lisa Wilde Unannounced Inspection 13th September 2005 10:00 Therapia Road DS0000060225.V252818.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 Therapia Road DS0000060225.V252818.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. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Therapia Road Address 26 Therapia Road East Dulwich London SE22 0SE 020 8946 2686 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) Odyssey Care Solutions for Today Lu Helen Cope Care Home 5 Category(ies) of Learning disability (0), Physical disability (0), registration, with number Sensory impairment (0) of places Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 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. 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” Therapia Road DS0000060225.V252818.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 one day in September 2005. The inspection was essentially based around discussions with the Registered Manager because they had not been present at the inspection of June 2005. All the service users were at day centres during this inspection and so the inspector conducted the tour of the building and their rooms in their absence, given that the manager had been aware that the inspector was turning up and had made the service users aware that the inspector may wish to enter their rooms. In addition the inspector spoke with a social worker of one of the service users following the inspection day. The inspector found that the home is offering a high standard of individual care and support to its service users but is being let down by the fact that the organisation says that the funding for the home does not allow them to provide enough staff on duty. Service users are being placed at risk of harm and evidence shows that there are regular instances where service users’ behaviour is impacting negatively on themselves and on other service users within the home because of insufficent staff in place to offer the required levels of support and monitoring. Therefore although generally the home consistently meets the majority of the National Minimum Standards and must be commended for the individual programmes that are in place, the immediate requirement for the organisation to increase staffing levels at the home must be met to ensure the immediate and ongoing safety and welfare of service users. What the service does well: Of the standards assessed at this inspection the home showed that: • potential service users and families are provided with all the information they need to make an informed choice about where to live in the service user guide. • service users needs and aspirations are fully assessed prior to them coming to the home and whenever circumstances change. • service users are given information and consulted about life at the home and supported to make decisions about their own lives. • service users are supported to increase their emotional independence and enhance practical skills through long-term personal development programmes aimed at eventual goals of move-on to less supported accommodation. • service users are supported to identify what they wish to do with their time and then supported to access the local community to undertake those activities. Service users are offered meaningful individual and group programmes both in and out of the home. • service users are supported to maintain relationships with their families and friends and develop new relationships as they choose. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 6 • • • • • • • service users’ physical and emotional needs are being met (apart from the staffing issue identified earlier) by staff or by using other external professionals. service users are protected by the management and administration of medication. service users’ complaints and comments are taken seriously and acted on. generally the home is clean, comfortable and safe with adequate and appropriate furniture and decoration in the communal areas and bedrooms. the staff team is effectively trained and qualified. the Registered Manager is qualified and trained and has the skills and experience to understand the needs of the service user and ensure that the home and staff team are able to meet those needs. the home operates systems that ensure the home is reviewed and develops in a way that places service users’ views at the centre of those processes. What has improved since the last inspection? What they could do better: 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. Therapia Road DS0000060225.V252818.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 Therapia Road DS0000060225.V252818.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): 1&2 The Service User Guide includes all the areas required by the standard meaning that some potential service users and families are provided with all the information they need to make an informed choice about where to live. The current Service User Guide is not in a language or format that could be understood by the current service users at the home which means that they are not being provided with the most useful information about what they can expect from the home. Service users needs and aspirations are assessed prior to them coming to the home and whenever circumstances alter so service users know the home can always meet their changing needs. EVIDENCE: There were previous requirements that 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 and that the Registered Individuals must ensure that the Service User Guide covers all areas required by Regulation 5 and Standard 1. The Service User Guide has been reviewed and now covers all areas required by the regulations and standards. The Registered Manager stated that the format of the guide is currently under review in terms of including pictures and changing the language but she is also currently meeting with other managers within the organisation to create a video guide that would be more useful to the service users at this home. The target timescale for the previous Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 9 requirement was 28/02/06 and as such the previous requirement is not unmet but is ongoing. (See Requirement 1) No new service users have been admitted to this home for a number of years so no initial assessments have taken place. Evidence from the files and from talking to the manager showed that a full assessment of someone’s needs and any areas of risk woud take place before this home decided whether it coud meet those needs, minimise any risks and offer someone a placement. Additional assessments take place with service users astheir needs or circumstances change. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, & 10 The day-to-day routines of the home ensure that service users are given information and consulted about life at the home and supported to make decisions about their own lives. Information at the home is stored confidentially and service users and their families are given information about the confidentiality policies and procedures so they know that their confidences are appropriately kept. EVIDENCE: There are service user meetings every fortnight where service users are encouraged to make decisions about the day-to-day running of the home. The manager discussed at length the efforts that are made to ensure communication methods for each individual are appropriate and then enhanced. The home operates a system of Person Centred Planning with the system of reviews being assessed currently to allow service users to be at the centre of their own reviews with all professionals’ agendas and needs being met elsewhere. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 11 All service user information is held in the main office, which is kept locked when not in use. The service user guide includes information about how the home and staff will handle information held about service users. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 & 15 Service users are supported to increase their emotional independence and enhance practical skills through long-term personal development programmes aimed at eventual goals of move-on to less supported accommodation. Service users are supported to identify what they wish to do with their time and then supported to access the local community to undertake those activities. Service users are offered meaningful individual and group programmes both in and out of the home. Service users are supported to maintain relationships with their families and friends and develop new relationships as they choose. EVIDENCE: The manager discussed each service users individual programme in detail and showed that they were individual to each person’s needs and wishes and focussed on people getting out of the house and into the local community. Activities take place in the home in the evenings and at weekends. Service users generally attend a local day centre for two days a week with extra days being negotiated where possible. On the day of the inspection all service users were out. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 13 All service users are being supported to go on holiday this year. The manager felt that service users at this home are working towards less supported accommodation in the very long term as the home aims to develop their personal and practical skills and emotional independence. Service users are supported to maintain and develop contact with their families where possible. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 14 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 & 20 Service users’ physical and emotional needs are being met (apart from the issue identified and addressed under the staffing standards) 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. The current 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 manager talked thorough all service users current health needs and how the home aims to meet those needs. Service users have dental appointments every month and other appointments are made on an individual basis. The home operates thorough and effective medication procedures and staff show awareness of the effect if the medications they administer and the need for consistent monitoring of the procedures. Medication stocks are checked twice daily and the local pharmacist is involved with the home, offering training and undertaking annual inspections. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 15 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 The complaints procedure is operated effectively and service users’ complaints and comments are taken seriously. Investigations are undertaken to make sure that service users know that if they have a problem, their views are listened to and acted upon. EVIDENCE: The home has an effective complaints procedure and the complaints books showed that service users are supported to make complaints which are recorded and actioned quickly by staff or management. The outcome of any action is recorded with timescales but there is currently no record of whether the complainant was satisfied with the outcome. (See Recommendation 1) Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 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, 25, 26, 27 28, 29 & 30 Generally the home is clean, comfortable and safe with adequate and appropriate furniture and decoration in the communal areas. Bedrooms are large enough and are personalised to individual service users tastes. Service users at this home do not need a large amount of specialist equipment but what they do need is effective and regularly assessed. EVIDENCE: There was a previous requirement that the Registered Provider must ensure that all repairs to the premises are completed within reasonable timescales. The timescale for this requirement had not expired by the time of this inspection but the Registered Manager reported that there were still difficulties with getting repairs and decorations met within a reasonable timescale. On the tour of the building there was evidence of necessary decoration work in the hallways and bathrooms. One of the toilets is not in use at the moment but there are three others in use. One service user is about to have their room refurbished because of their individual needs that require a built in wardrobe and different type of sink. The previous requirement is ongoing but revised slighty to include decoration work as well as repairs. (See Requirement 2) Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 17 Bedrooms meet the size requirements and one is ensuite. Bedrooms have all been personalised to service users’ individual tastes. The only adaptations in use within the home are grab rails and bars and a raised toilet. These have all been checked recently by an occupational therapist to ensure their continued suitability. On the day of the inspection the home was clean and hygienic. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 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): 32, 33 & 35 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. The staff team is comprehensively trained and qualified which means that service users receive support and care from a team that is confident and knowledgeable. EVIDENCE: There were previous requirements that 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 and that 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 Manager had written to the inspector explaining that technically staffing levels had not been reduced but at point of transfer of this home from Southwark Social Services to Odyssey the additional staffing that had been in place was not transferred. The organisation has made budget adjustments and increased the staffing back to 25 of the additional staffing that had been in place and plans to increase it to 75 in October 2005. The manager and inspector discussed the current issues within the home regarding staffing levels and the needs of service users. In addition the inspector spoke with the social Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 19 worker of one service user who had serious concerns that their client’s behaviour had deteriorated significantly over the past eighteen months. Incident forms being sent through to the Commission from this home show that there are regular instances where service users’ behaviour is impacting negatively on themselves and on other service users within the home because of insufficent staff in place to offer the required levels of support and monitoring. An immediate requirement was made following additional discussions after this inspection with regard to staffing levels. (See Requirement 3) The inspector could not examine the recruitment and personnel records for this home as they are kept at the head office. The inspector will be arranging to view the records at a later date following this inspection. All staff have recently attended Person Centred Planning training. There is a quarterly training day at the home and at the last the community pharmacist attended and offered medication training. Staff undertake the core statutory training and then undertake a variety of individual courses to meet the particular needs of the service users. All staff either hold or are undertaking the NVQ Level 3 in Care or if they are newly recruited they are still undertaking their Induction and Foundation programme based on the Learning Disabilities Award Framework. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 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 & 39 The Registered Manager is qualified and trained and has the skills and experience to understand the needs of the service user and ensure that the home and staff team are able to meet those needs. The systems, procedures and policies in the home are operated effectively and the home is well run. The home operates systems that ensure the home is reviewed and develops in a way that places service users views at the centre of those processes. Given the limited communication abilities of some service users more can be done to gather the views of service users families and other stakeholders to ensure that a full a picture as possible is gained of the service that the home offers. EVIDENCE: The Registered Manager has almost completed the NVQ Level 4 Registered Managers Award and the NVQ Level 4 in Care. She has been the manager of this home since 2003 and before that worked at the home as the deputy manager and as project worker. In total she has around twenty years experience in the care field. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 21 The home conducts at least annual reviews with the service users and completes quarterly returns to the borough organisation that report on identified indicators. There is a local business plan for the home. The home does not use an externally accredited quality assurance systems that focuses on the views of service users. Staff are in contact with family of service users as appropriate but the home does not conduct an annual review of the views of family and other stakeholders as part of its development process. (See Requirement 4 and Recommendation 2) Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Therapia Road Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000060225.V252818.R01.S.doc Version 5.0 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 Standard YA1 Regulation 5 Requirement The Registered Individuals must ensure that the Service User Guide covers all areas required by Regulation 5 and Standard 1. Previous requirement but timescale for action had not expired by this inspection. The Registered Provider must ensure that all repairs and decoration to the premises are completed within reasonable timescales. Unmet requirement: Previous requirement but timescale for action had not expired by this inspection. Previous unmet timescale before that 28/02/05. The Registered Individuals must ensure that staffing levels at the home are increased to ensure that service users are at all times provided with sufficient care and support to maintain their own health, safety and welfare (both in and outside of the home) and that all service users are protected from physical harm from other service users. A copy of the revised rota must be sent to the Commission. DS0000060225.V252818.R01.S.doc Timescale for action 28/02/06 2 YA24 23 (2) (b) 30/11/05 3 YA33 18 (1) (a) 05/10/05 Therapia Road Version 5.0 Page 24 4 YA39 12 (3) The Registered Manager must ensure that an annual survey (or other form of annual audit) of service users families and other stakeholders takes place that then feeds into the annual review of the service and the local business plan. 31/03/06 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 YA22 YA39 Good Practice Recommendations The Registered Manager should ensure that the complaints records show whether the complainant was satsified with the outcome of the complaints investigation. The Responsible Individuals should consider investigating and employing a professionally recognised quality assurance tool within the home. Therapia Road DS0000060225.V252818.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark 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 Therapia Road DS0000060225.V252818.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. 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!