Inspection on 16/01/06 for Therese Care Home

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Therese Care Home 31/08/07

Therese Care Home 16/03/07

Therese Care Home 28/11/06

Therese Care Home 27/06/06

Therese Care Home 28/06/05

Therese Care Home 09/12/04

Therese Care Home 29/07/04

Therese Care Home 03/12/03

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Delrose House Ltd

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Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Therese Care Home 144 Gassiot Road London SW17 8LE Lead Inspector Louise Phillips Unannounced Inspection 09:30a 16 , 18 and 25 January 2006 th th th Therese Care Home DS0000010231.V272691.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 Therese Care Home DS0000010231.V272691.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. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Therese Care Home Address 144 Gassiot Road London SW17 8LE 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) 020 8767 5407 Ms Iolenta Castelino Ms Iolenta Castelino Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may provide accommodation and care for one named service user over the age of 65. The category MD(E) must be removed once this service user is no longer accommodated. 28th June 2005 Date of last inspection Brief Description of the Service: Therese Care Home provides care and support to three residents with a mental disorder. The home is a two-storey terrace house with a small garden to the front and larger garden to the rear of the home. The home is situated close to the busy shopping centre of Tooting Broadway, within easy access of the public amenities and transport links served by the area. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three days with time spent talking to staff, residents and the owner of the home. A tour of the premises was carried out and staff and care records were inspected. What the service does well: 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. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 6 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 Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 7 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): 2, 3, 4 and 5 There is an adequate process for new residents moving to the home. Residents contracts have not been agreed by all relevant people. EVIDENCE: Since the last inspection no new residents have moved into the home. The home has a ‘referrals and admissions policy’ that details the process of assessing potential residents and their having trial periods to the home before moving in. Each resident file contains a copy of their placement agreement/ contract with the home. These still remain at varying stages of being signed, where either the manager or resident have not signed these agreements. Therefore the requirement for all relevant parties to sign this has been restated. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The care plans continue to not provide adequate information about activities involving each resident, or the potential risks involved in these. EVIDENCE: The care files for the three residents at the home were examined. Records demonstrate that an annual review of each residents care has taken place between the resident, their care manager and the owner of the home. Some improvements have been made to include the interests and activities of each resident in their care plan. However during the inspection the staff and one resident discussed plans for their “…starting voluntary work in two weeks…”, and a referral that had been made for them joining a group, though these were not included in the care plans for the resident. The care plans must be developed to include these areas and issues from the annual review, detailing how the home plans to support the resident with these. The requirement has been restated for the second consecutive inspection, for the care plans to fully detail all the support needs of each resident. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 9 In addition, improvements need to be made to the risk assessments for the residents as the previous inspection required that restrictions on the freedom of residents is clearly documented in their care plan and risk assessment. Findings indicate that for one resident an addition has been made to their care plan, that they need to be escorted when going out, but there was no risk assessment or plan as to how this is managed in the context of meeting the persons needs and wishes to go out and the staffing levels at the home. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 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 the following standard(s): 11, 12, 16 and 17 Routines for the home do not happen as prescribed. Residents pursue individual interests and they generally like the food offered at the home. EVIDENCE: The previous inspection identified that there is a ‘daily routine’ document displayed on the wall of the office, that prescribes times throughout the day that activities are to be carried out, eg. “…9:05am – check residents awake and ready for breakfast …11:40am – residents to bathe as necessary …3:00pm – check residents rooms, clean as necessary and do their laundry …6:15pm – evening meal served…” Observation during the inspection indicate that the routine of the home is not as rigid as the document describes and that the staff have a good awareness of what needs to be done throughout the day. Examples of this were that on arrival at the home one resident was having their breakfast, whilst another said they had their breakfast much earlier, and laundry was being done Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 11 throughout this time. The owner described that the document is as a reminder for staff to carry out their duties. It is recommended that this is removed, or a more flexible format developed to reflect what actually does occur in the home, as in its current form the document appears outdated. Two of the residents spoke with the inspector with one describing in detail the artwork they were doing and how they enjoy listening to music. The other resident said that they enjoy watching the television and talking with the staff on duty. Both residents commented on the food, with one saying that the “…food is good…I like it…”, and one commenting that there is “…too much rice…”, although when prompted added that this is “…not all the time…”. The menu showed that rice is included with meals approximately three times a week and that this is varied with a roast dinner, pasta dishes and various other meals throughout the week. The resident said that if they did not want the food offered then staff were “…good at making something else…” for them to eat. Therese Care Home DS0000010231.V272691.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): These areas were not assessed on this occasion. EVIDENCE: Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 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 the following standard(s): 23 The protection of the residents is at risk due to the lack of staff training in this area. EVIDENCE: The home has some information about different forms of abuse and who to contact in the event of this happening at the home. However, there is no record that staff working at the home have received any training in the Protection of Vulnerable Adults. A requirement has been made to address this. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 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 the following standard(s): 24 and 28 No improvements have been made to the décor or communal space for the residents at the home. EVIDENCE: The last inspection required that the hallways, bathroom and bedrooms be redecorated, due to stained and chipped paintwork; creased and missing wallpaper. It was also required that light-shades be installed to all the lights throughout the home to create a more homely feel. No steps have been taken to address these issues or redecorate these areas, and the requirements have been restated. The previous inspection also recommended that the office be used as a communal area for the residents, due to the existing lounge/dining area being very cramped, with two dining tables and three armchairs taking up most of the floor-space. Again, no steps have been taken to re-dress this, and the recommendation is restated. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 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 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, 34 and 35 Staff recruitment procedures do not protect the residents. Staff are not adequately trained or experienced for meeting the needs of the residents. EVIDENCE: The inspector returned to home on second occasion to view the staff files, as these were not held at the home. The owner of Therese Care Home brought the Criminal Records Bureau (CRB) checks for each member of staff into the Wimbledon CSCI office on separate occasion. The files for the three staff employed at the home were examined. Findings indicate that recruitment checks need to improved to protect the residents. In particular the one staff member had a CRB check carried out through a previous employer, and the Registered Person must ensure they have a new check done with them as the current employer. In addition, the Registered Person must ensure that a POVA First check is carried out on all new staff before their starting work at the home. Each staff file contains a copy of their contract, a statement of the terms and conditions of their employment. The contract for each member of staff states that they work 85 hours a month, however this does not correspond with the actual hours worked by any member of staff. A rota for the home indicates that the typical number of hours worked a week for each member of staff Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 16 varies between twenty and twenty-five, though this is not including sleep-in duties. It is required that the staff contracts detail the actual hours that staff are employed to work each week, including sleep-in duties. Staff files indicate that none of the staff had any previous experience of working with adults with mental health problems. None of the staff hold the NVQ level 2 in care qualification. Also none of the staff working at the home have received training in mental health, dealing with challenging behaviours; or up-to-date training in medication administration, first aid or fire safety. The requirement from the previous inspection to address this has been restated for the third consecutive inspection. If the home fails to address staff training needs within the timescale given then enforcement action may be considered by the CSCI. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 17 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): These standards were not assessed on this occasion. EVIDENCE: Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 18 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 3 3 3 2 Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 2 X X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Therese Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000010231.V272691.R01.S.doc Version 5.0 Page 19 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 YA5 Regulation Schedule 4(8) Requirement The Registered Person must ensure that each resident user has a statement of the terms and conditions of their accomodation (contract), that has been signed and agreed by all relevant parties. (Previous timescale not met). The Registered Person must ensure that the care plans fully detail all support needs for each resident. (Previous timescale not met). The Registered Person must ensure that there are risk assessments and risk management plans in place for each resident. The Registered Person must ensure that all staff working at the service receive training in the Protection of Vulnerable Adults. The Registered Person must ensure that the hallways, bathroom and bedrooms are redecorated. The Registered Person must ensure that lightshades are Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 20 Timescale for action 31/03/06 2 YA6 15(1) & (2) 31/03/06 3 YA7YA9 13(4)(c) 30/04/06 4 YA23 13(6) 31/08/06 5 YA24 23(2)(d) 30/06/06 6 YA34 19(4) & Schedule 2 7 YA34 Schedule 4, 6(e) 8 YA35 18(1) provided on all lights throughout the home. (Previous timescale not met) The Registered Person must 31/03/06 maintain a Criminal Records Bureau check with them as the current employer for each member of staff. A POVA First check must be received for all staff prior to their commencing work at the home. The Registered Person must 30/04/06 ensure that the staff contracts detail the actual hours that staff are employed to work each week, including sleep-in duties. The Registered Person must 31/03/06 ensure that a training programme is formulated to ensure that care staff receive at least five paid training days a year and that this training is evidenced. The training must include fire safety, medication, food hygiene and first aid. (Previous timescale not met). 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 3 Refer to Standard YA16 YA28 YA32 Good Practice Recommendations The Registered Person should ensure that the ‘daily routines’ document is removed or a more flexible developed to reflect what actually does occur in the home. The Registered Person should covert the use of the office area to a communal area/ lounge for the use of residents. The Registered Person should ensure that all care staff at the home undertake the NVQ level 2 in Care qualification. Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Therese Care Home DS0000010231.V272691.R01.S.doc Version 5.0 Page 22 - 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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