CARE HOME ADULTS 18-65
MACA (Southbury Road) 87 Southbury Road Enfield Middlesex EN1 1PJ Lead Inspector
Brian Bowie Unannounced Inspection 20th September 2005 13:00 MACA (Southbury Road) DS0000010664.V251218.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 MACA (Southbury Road) DS0000010664.V251218.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. MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service MACA (Southbury Road) Address 87 Southbury Road Enfield Middlesex EN1 1PJ 020 8342 1593 020 8362 9004 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) The Mental After Care Association Jacqueline Konadu Osei Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10th January 2005 Brief Description of the Service: Southbury Road is managed by Together: Working for Wellbeing (formerly MACA), which provides services throughout the country for people with mental health problems. The home accommodates nine residents. There are three bedrooms on the ground floor and six bedrooms on the first floor. The home is wheelchair accessible. There is an adapted bathroom and toilet on the ground floor. The building has a lounge, dining room and kitchen. There is a separate laundry and a spacious garden to the rear of the building. The home is within walking distance of the local shops. There are good public transport links. The home aims to provide a supportive environment where residents can maintain and develop their independence. MACA (Southbury Road) DS0000010664.V251218.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 and lasted 5 hours. The manager was present throughout and assisted with the inspection. The home was looked round and 5 of the 6 people resident in the home at the time of the inspection were spoken to in order to get their views about the home. On the day of the inspection two of the residents were temporarily in hospital so that their mental health needs could be reassessed and there was one vacancy. Care staff on duty were spoken to and the handover session between the morning and afternoon shift was observed. A variety of records, including careplans, risk assessments and health & safety documents, were looked at. The area manager for the home was also present throughout the inspection and was interviewed for his assessment on the standard of care provided by the home. The overall impression from the inspection was of a home that has achieved a good standard of care over a long period of time within a friendly, homely and supportive environment, and which is now aiming for still higher standards of care. What the service does well:
Residents feel at home and relaxed at Southbury Road because staff pay close attention to meeting their individual needs and wishes. The majority of the residents spoken to said they enjoyed living at the home and were happy with the quality of care they were getting with several saying: ‘I like it here.’ There is an experienced and motivated team of staff at the home. As a result residents benefit from being supported by staff who have got to know them well and who can respond appropriately to their needs and wishes. As a result residents are maintaining and improving their independence skills in areas such as cooking, shopping, cleaning, budgeting and socialising in the community. The home is good at offering choices to residents, one of whom said: ‘I feel I can do what I want when I want to.’ The home supports residents to maintain links with their families and relatives, with one resident visiting his family on the day of the inspection. Staff keep in touch with residents when in hospital, with one member of staff visiting both of the residents currently in hospital on the day of the inspection. Both the manager and the area manager are committed to improving further the standard of care provided for residents and ensuring it is based on a holistic and person-centred approach, which aims to meet the individual needs
MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 6 and wishes of each resident, and which reflects current thinking about what is best practice in the mental health area. 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. MACA (Southbury Road) DS0000010664.V251218.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 MACA (Southbury Road) DS0000010664.V251218.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): 2 The home is good at ensuring people moving into the home have their needs and wishes assessed so that the home can be confident that it can meet these needs and wishes. EVIDENCE: Interviews with the manager and staff confirmed that residents were settled in the home and considered that their needs were being met. The case records looked at showed that the needs and wishes of each resident had been individually assessed and detailed careplans drawn up. The manager confirmed that she visits prospective residents before they move in and that they are able to visit the home before deciding if they are happy to move in. Where residents indicated they wished to move on from the home this was followed up, and in one recent case a resident had moved on to another home. MACA (Southbury Road) DS0000010664.V251218.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 Residents benefit by having care plans which set out clearly and in detail how their needs and wishes will be met by the home. EVIDENCE: The care plans sampled were detailed and covered the key aspects of the resident’s life. Staff have regular 1-to-1 meetings with the residents for whom they are the ‘keyworker’. Notes of these meetings were seen and showed how the aims listed in the care plan were being followed through by staff. There was positive written feedback from professionals involved with the home, including social workers and community psychiatric nurses, which indicated that the home had care plans for each resident which were being followed and reviewed regularly. MACA (Southbury Road) DS0000010664.V251218.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): 13, 14, 15 Residents are getting a better quality of life because of the good links with the local community, the range of leisure activities available and the close contact residents have with friends and family. EVIDENCE: On arrival at the home a resident was seen playing scrabble with a member of staff. Residents were participating in a variety of leisure activities, both inside and outside of the home. These included the cinema, bingo, visits to the local park, going to clubs. One resident said: ‘There are plenty of things to do.’ Residents said they use the local shops and cafes and make use of public transport to get around. One resident gets out and about by driving his own car. From time to time residents go on outings or day trips organised by the home in response to what people living at the home have requested. Some residents were having regular contact with their families which they clearly valued. Residents said that their friends and family were welcome to visit them at Southbury Road.
MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 11 MACA (Southbury Road) DS0000010664.V251218.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 Staff are good at supporting residents in a way which makes sure their physical and health needs are met. EVIDENCE: Residents themselves commented that they thought that staff were good at responding to their individual needs, with one resident saying: ‘When I first came here I stayed in my bedroom a lot, but staff were very patient with me and encouraged me to come out of my room. I like it here-it’s very nice.’ Written feedback from families and the GP for the home indicated that they were satisfied with the overall care provided to residents at the home. The community nurses for the residents had also written that they considered the home had a good understanding of the residents’ needs. The interviews with both residents and staff confirmed that the health needs of the residents were being addressed by the home, with one resident having been to see a dietician on the day of the inspection. MACA (Southbury Road) DS0000010664.V251218.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): 22 The home has a satisfactory complaints procedure so that residents and relatives feel confident their complaints and concerns will be listened to. However the home needs to improve its recording of complaints. EVIDENCE: The home has policies and procedures in place in relation to reporting and investigating complaints. The complaint record indicated that no complaint had been made since the previous inspection. However a complaint had been made by a relative which was being investigated but had not been recorded in the complaints book. It is required that all complaints relating to the running of the home are clearly recorded and indicate action being taken and the outcome of the complaint. MACA (Southbury Road) DS0000010664.V251218.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): 24,25 Residents at Southbury Road enjoy an attractive and comfortable living environment which adds considerably to their quality of life. The home is good at enabling and supporting residents to have their bedrooms how they wish to have them. EVIDENCE: The home provides a comfortable and homely environment well suited to meeting the needs of the current group of residents. Throughout the inspection it was noted that residents were very comfortable and relaxed in the home. An extension to the downstairs area means that residents with mobility difficulties can be accommodated on the ground floor. The bedrooms seen clearly reflected the individual tastes and preferences of each resident. One resident said he had been given the opportunity to move to a downstairs room which he was pleased about, and commented: ‘I like my bedroom- it’s nice and big.’ He had also been provided with a freezer and fridge in his bedroom so that he could be more independent about his shopping and cooking. MACA (Southbury Road) DS0000010664.V251218.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): 33 Residents benefit from a committed and experienced team of staff who are supported well by the management team. EVIDENCE: The home has permanent staff which are supplemented as needed with staff from Together’s own bank of staff, with no use made of agency staff. As a result residents benefit from continuity of care. There were positive comments from residents about staff, including: ‘I like the support here- staff are very patient.’ One relative had written: ‘We’re very happy with staff levels and input and their wish for patients’ independence in what is a very taxing task.’ Both care staff on duty throughout the inspection were observed and spoken to. The handover session between morning and afternoon shifts was observed and showed that staff had a good knowledge and understanding of the needs of each resident, with close attention being paid to ensuring that residents got a high standard of care. A new member of staff confirmed that they had had a proper induction into the job and felt well supported in what they were doing. MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 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 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): 37,42 Residents benefit from living at Southbury Road because the home is run in the best interests of the residents. The home has good procedures in place in relation to health and safety which help to ensure residents are protected at all times. EVIDENCE: The manager, Jackie Osei, is knowledgeable and perceptive about the needs of residents and staff. The area manager for the home was also interviewed and is committed to raising standards at the home still further. As a result there is now a greater focus in the home on empowering residents and ensuring that the home aims to achieve best practice in the mental health area. As a result what the residents get out of the home is a caring and supportive place to live where they are being helped to get as much as possible out of life, and where their independence skills are developed as far as possible. MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 17 A range of health and safety records was looked at and were satisfactory. These included the accident book, electrical and gas certificates and fire safety records. MACA (Southbury Road) DS0000010664.V251218.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 x x x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x x x Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
MACA (Southbury Road) Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x DS0000010664.V251218.R01.S.doc Version 5.0 Page 19 NO 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 YA22 Regulation 22 Timescale for action The registered persons must 14/10/05 ensure that all complaints relating to the running of the home are clearly recorded and indicate action being taken and the outcome of the complaint. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations MACA (Southbury Road) DS0000010664.V251218.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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