Inspection on 14/10/05 for Townley Road, 2-3

This inspection was carried out on 14th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Townley Road, 2-3 12/06/08

Townley Road, 2-3 24/08/06

Townley Road, 2-3 04/01/06

Townley Road, 2-3 24/03/05

Townley Road, 2-3 14/12/04

Townley Road, 2-3 11/03/04

Similar services:

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Ashwood House (Leyton)

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

CARE HOME ADULTS 18-65 Townley Road, 2-3 Dulwich London SE22 8SW Lead Inspector Lisa Wilde Unannounced Inspection 11:00 14 October 2005 th Townley Road, 2-3 DS0000007000.V253084.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 Townley Road, 2-3 DS0000007000.V253084.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. Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Townley Road, 2-3 Address Dulwich London SE22 8SW 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 8299 1841 020 8299 0820 Hexagon Housing Association Ms Norma Smellie Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 10 patients adults with mental health disorders (on leave), to include one patient aged above 65 years In addition to the 10 (ten) residential service users, the home may provide day care facilities for up to two extra service users (aged 18-60 years) with mental health disorders, for the purposes of rehabilitation, given that at least two of the residential service users are off the premises during the day care period 24th March 2005 Date of last inspection Brief Description of the Service: Townley Road is a care home providing care, nursing and accommodation to ten service users with mental health needs. It aims to provide placements of two to three years to enable service users to move on to a range of other housing options. It is owned and run by Hexagon Housing Association The home is located in East Dulwich, close to the train station, shops, banks, a post office and bus services. The home is a three storey residential building with bedrooms on the first and second floors. All bedrooms are single. There is a communal lounge, dining/games area and quiet room along with a large kitchen. There is a small kitchenette on the first floor. There is no passenger lift and the home is not wheelchair accessible. There is a garden to the rear. At the time of this inspection there were no vacancies at the home. Townley Road, 2-3 DS0000007000.V253084.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 October 2005. The inspector spoke with the manager, staff and four of the service users. The focus of this inspection was on the core standards that had not been assessed at the last inspection, as this home has consistently shown that it is meeting the National Minimum Standards in most areas. This inspection again found a high level of care being provided at this home with all of the standards that were assessed meeting the National Minimum Standards. Service users expressed high levels of satisfaction with the service saying that they “loved living here”, “had no problems at all” and that “staff are very good.” What the service does well: What has improved since the last inspection? Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 6 This was the first inspection of this home by this inspector so it is harder to say what has improved. The requirement and recommendations from the last report that had been met by this inspection show that the home has got better at recording complaints and making care plans understandable and centred around service users’ positive skills. 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. Townley Road, 2-3 DS0000007000.V253084.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 Townley Road, 2-3 DS0000007000.V253084.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 undertakes a full assessment of a prospective service user’s need following their initial referral. The team decides together whether it is able to meet those needs so that service user knows from the outset that the home has established if it can offer them an effective service. EVIDENCE: The manager described the assessment process, which includes a written referral being made by South London and Maudsley Team and then the manager going out to visit the service user with another member of staff to undertake the home’s assessment. These assessments were seen on file for a random sample of service users and covered all the required areas. The team then decides if they can meet the service user’s needs and then the service user is invited for a series of trial stays. Townley Road, 2-3 DS0000007000.V253084.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, 8 & 9 Service users know their needs and goals are described in their individual plans and action is identified to meet those needs and achieve those goals. Staff consult with service users about day-to-day life at the home and their views are listened to and changes made where possible. Risk is seen as an essential part of life at this home but identified risks are managed and minimised so that service users are given information to make choices about what are reasonable risks to take. EVIDENCE: There was a previous recommendation that the Registered Provider should ensure that Service User Plans include the independence skills of service users, and are designed to allow service users to understand them without unnecessary support from staff. The inspector examined random samples of files and these showed that care plans are thorough, include evidence of the service users participation and are reviewed regularly, the care plans appeared to be language that could be understood by service users and they later confirmed that they knew what their care plans were about. The wording of the plans shows that emphasis is Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 10 being placed on the positive skills and achievements of service users in order or them to enhance these skills. Service users are consulted through their key work sessions and residents’ meetings. There is a Tenant Participation Group within the organisation that is sometimes attended by service users from this home. There are annual questionnaires, which are completed and the results audited. Currently the action taken as a result of those audits is not documented (See Recommendation 1) (See also Standard 39) Risk is assessed thoroughly as part of the initial assessment and then on an ongoing basis throughout someone’s stay at the home. The Registered Manager discussed some examples of how service users have been supported to take reasonable risks with their public transport, accessing the community and going on holiday abroad alone. Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13 & 14 Service users are offered a variety of activities and development opportunities within the home. They are assisted to identify activities and programmes within the local community and then are supported to access those opportunities as required. EVIDENCE: The Registered Manager talked about the individual programmes of service users and the inspector examined files and spoke with service users. All the evidence showed that service users are being supported to identify appropriate activities and opportunities for personal development and are then enabled to access those opportunities as they choose. Service users are allowed to come and go as they please during the day and were seen to be part of the local community during the inspection. Service users undertake the chores of the house on a rota basis with staff assistance as part of a rehabilitation approach. The home offers several groups in house throughout the week which include medication compliance, hearing voices, music appreciation, health, women’s/men’s group, creative writing, exercise, grooming/normalisation, videos and current affairs. Townley Road, 2-3 DS0000007000.V253084.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): 18 Service users confirmed that they are offered personal support from staff as they choose to have it. Care plans show that personal care needs are met by staff or by accessing other professional services within the community. EVIDENCE: Service users are offered varying levels of personal support, dependent on their needs and they confirmed that staff help them as they want to be helped. Nursing interventions are offered should someone’s mental health state require more than social or emotional support. Care plans outline how service users are to be supported to maintain their life at the home. Staff showed awareness of these care plans. Townley Road, 2-3 DS0000007000.V253084.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 Service users know how to complain and are listened to when they do voice concerns. The complaints policy and procedure is clear and effective and action is taken in response to service users’ issues whether raised formally or through day-to-day systems such as residents’ meetings. EVIDENCE: There was a previous requirement the Registered Provider must ensure that a complaints record is maintained at the home to ensure service users are supported to understand the process, and timescales and actions are clear. This had been met and records of investigation into complaints are being thoroughly recorded. Day-to-day complaints and issues are recorded in the residents’ meeting but there is currently no record made of any action taken and feedback given in the following meeting. (See Recommendation 2) Service users said that staff listen to them. Townley Road, 2-3 DS0000007000.V253084.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, 26, 27, 28, 29 & 30 The home is homely, comfortable and clean throughout. The communal areas provide a number of different spaces, which allow service users to be together or choose to spend time alone outside of their rooms. Service users rooms are large enough and personalised to their own individual taste. EVIDENCE: The home is a three storey residential building with bedrooms on the first and second floors. All bedrooms are single. There is a communal lounge, dining/games area and quiet room along with a large kitchen. There is a small kitchenette on the first floor. There is no passenger lift and the home is not wheelchair accessible. There is a garden to the rear. There are four toilets, two baths and one shower and these are decorated in a homely manner. The inspector saw one room, which was individualised to the service users’ personal taste and which they said they were happy with. Current service users do not need any physical adaptations. The manager has undertaken an assessment under the Disability Discrimination Act and they have determined that it is not feasible to make this building wheelchair accessible. The manager is accessing information and packs to assist those Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 15 with sensory impairments should they receive a referral from someone with such needs. The home was clean and hygienic throughout. There was a previous recommendation that the Registered Provider should ensure that the flow of water to the upstairs bathroom is increased. The Registered Manager confirmed that this has been done. Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 16 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 Service users are supported by a competent and qualified staff team. There are sufficient nurses and NVQ qualified staff on duty to meet the needs of the service users. The organisations’ recruitment policy and procedure is robust and effective. The required checks are carried out prior to staff starting employment and service users are protected by the home’s practice in this area. EVIDENCE: The home is more than meeting the target of 50 of its care being provided by staff who hold the NVQ Level 2 in Care or equivalent. Staff were able to discuss service users’ needs in detail and highlight how they were meeting those needs. The homes recruitment policy and procedure is appropriate and effective. This standard was assessed as met at the last inspection in March 2005 and the inspector saw the CRB check for the new member of staff who is due to start at the home in the next week. Townley Road, 2-3 DS0000007000.V253084.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): 37, 39 & 42 The Registered Manager is fit to be in charge. She has the necessary skills, experience and training to identify and understand the needs of service users and be able to manage the home to ensure that staff can meet those needs. Service users are benefiting from a well run home because of this. The organisations’ quality assurance system and the homes’ consultation with service users means that service users’ views are gathered and form the basis of the home’s review and development. The health, safety and welfare of service users are being promoted and protected by the home’s procedures and practice throughout the building. EVIDENCE: The Registered Manager has been in post for around fourteen years. She is a qualified nurse and holds the NVQ Level 4 in Management along with the Certificate and Diploma in Management. Since the last inspection she has undertaken training around motivation, context, structured investigation, CPA, Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 18 communication and record keeping. Throughout the inspection she evidenced her detailed awareness of the needs of the home and of service users. The home draws up development plans based on the views of service users and staff. These were seen and action has been taken to address the issues identified. Currently these action plans do not include any timescales for completion. (See Recommendation 3) The home has achieved Investors in People accreditation and is about to start its own internal system of quality assurance with regard to the care provided. Staff questionnaires have been completed as part of this audit and there are about to be service user interviews undertaken. The inspector saw all the health and safety checks and certificates and these were all as required. On the tour of the building there were no health and safety issues identified. Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 19 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 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Townley Road, 2-3 Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000007000.V253084.R01.S.doc Version 5.0 Page 20 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. Standard Regulation Requirement Timescale for action 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 YA8 YA22 Good Practice Recommendations The Registered Manager should ensure that action taken as a result of the service users’ questionnaires is recorded and feedback to the service users. The Registered Manager should ensure that action taken in response to service users’ comments, concerns and complaints in residents’ meetings is recorded in the minutes along with any feedback that is given at following meetings. The Registered Manager should ensure that the annual development plans include timescales for completion of any identified action. 3 YA39 Townley Road, 2-3 DS0000007000.V253084.R01.S.doc Version 5.0 Page 21 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 Townley Road, 2-3 DS0000007000.V253084.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. 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