Inspection on 19/12/06 for Trevelyan Road

This inspection was carried out on 19th December 2006.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trevelyan Road 08/12/08

Trevelyan Road 02/02/06

Trevelyan Road 22/07/05

Trevelyan Road 31/01/05

Trevelyan Road 29/07/04

Trevelyan Road 03/02/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

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 Trevelyan Road 140 Trevelyan Road Tooting London SW17 9LN Lead Inspector Adrian Gordon Unannounced Inspection 19th December 2006 and 12 January 2007 10:30 th Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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 Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trevelyan Road Address 140 Trevelyan Road Tooting London SW17 9LN 020 8672 9977 020 8672 9977 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) Mr Clifford Steven Oakley Vincent Ethelbert Hurley Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 12th May 2006, service users with a Mental disorder, excluding dementia can be accommodated within the home. Date of last inspection Brief Description of the Service: Trevelyan Road provides a service for four adults of African Caribbean origin, who have mental health problems. All residents are male and are supported by male members of staff. The home is a two storey domestic property with a garden to the rear. The home provides a lounge, four bedrooms, kitchen/diner and bathing and toilet facilities. Trevelyan Road is situated close to local transport facilities and shops. Information about the service is provided in the Statement of Purpose. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over the course of two days on 19th December 2006 and 12th January 2007. It consisted of examination of records, tour of premises and discussion with staff on duty. The manager was available at the second visit. The inspector had the opportunity to talk to all the residents. Feedback questionnaires were also returned by three staff and two residents. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be improved to be more centred on the individual, including meaningful goals and how these will be met by the home. Records at the home were disorganised and a system must be put in place to ensure they are maintained to a better standard. A quality assurance system must be implemented to ensure that residents are able to feedback on a formal basis. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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 Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are suitably assessed before admission to ensure the home is suitable. EVIDENCE: There have been no new admissions to the home since the last inspection. All the current residents have been there for over three years and say they like it there. Records show that residents have an assessment before admission. The service is appropriate for the residents that live there. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning information must be improved in order to ensure individual needs and goals are met. EVIDENCE: Care planning information was disorganised and documentation difficult to find. The manager was able to locate up to date care plans for each resident and these included goals, however these were not always specific to the individual. One goal was to ‘promote independence’ but it did not say how this was to be done and there was no process of evaluation. The system for care planning must be reviewed to ensure that it is meaningful to residents and that staff know how to meet individual goals. Care plans are hand written and in parts difficult to read. Staff do not have access to a computer at the home. This should be provided in order to make case records easier to update and more legible. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 10 Examples were seen of residents being involved in making decisions about their lives. Care plans are signed by residents and minutes of reviews show that their views are included. Up to date risk assessments are in place, including a risk management plan. These were individualised for each resident. One assessment was seen to have been reviewed due to a change in a residents behaviour. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to take part in appropriate activities and are supported to take responsibility for their daily lives. EVIDENCE: All residents spoke about the activities that they can participate in. These include the Hope Day Centre where they can enjoy, for example, pool and table tennis. Residents are able to go to the local shops and community facilities and all have a key to the front door. Visitors are encouraged to come to the home. One resident confirmed they get visits from family. All residents were seen to be relaxed and at home. Residents rights are respected, for example, by staff knocking on bedroom doors. Residents are encouraged to participate in household tasks and have individual responsibility for their bedrooms. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 12 A menu is kept on a notice board outside the office. All residents said that they liked the food. A cook comes in twice a week to prepare Caribbean food which residents look forward to. The rest of the time, residents are supported to cook by staff. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being in a setting which meets their cultural needs. EVIDENCE: Staff were observed to treat residents with respect. Residents are encouraged to make choices and decisions about how they prefer to live. This includes what to do in the day time, for example one resident does not wish to attend the day centre. The registered persons talked positively about the advantages of having a staff team which reflects the cultural background of residents. For example, communication is often more effective and staff are able to form better relationships where external services can sometimes find it difficult to ‘connect’. This cultural understanding has promoted residents mental health and led to successful placements. The example was given of a resident who used to make reference to something specific to Caribbean culture which was affecting his mental health. Staff were able to recognise this where other professionals had not fully understood. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 14 Medication is stored appropriately and medication administration records were correctly filled in. Medication information includes details of any allergies for each resident. A book is used to record medication received and returned. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the systems in place at the home. EVIDENCE: There have been no complaints since the last inspection. Residents confirmed that they knew how to complain should they need to. One resident said ‘I can make a complaint to staff’. A copy of the local interagency procedures for the Protection of Vulnerable Adults (POVA) is kept in the office, although this was out of date. This must to be replaced by the updated London Borough of Wandsworth procedures. Staff recently attended POVA refresher training. All residents have there own bank account. Residents are supported by a member of staff to withdraw money when needed. Bank books examined were up to date and tallied with money kept at the home. One resident would benefit from getting professional financial advice to manage their account more effectively. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 24, 25, 28, 30 Residents live in a clean, comfortable environment which meets their needs. EVIDENCE: The outside of the home is in keeping with other properties and is not recognisable as a care home. On the ground floor there is a comfortable communal lounge and kitchen, which leads to a rear garden. A broken plug socket in the lounge must be replaced. The kitchen would benefit from being updated and repainted. A small office is located on the first floor. The bathroom was suitable for residents but the end panel of the bath must be fixed. The interior of the home was clean and tidy throughout. Resident bedrooms are on the top two floors. Residents said they were happy with their rooms. Two residents were happy to show their rooms. These were Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 17 of a good size and personalised with pictures and posters. One resident had a music system in their room. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent staff team. EVIDENCE: The staff team is culturally representative of residents in the home. Staff were observed to get on well with residents and were knowledgeable about individual needs. One member of staff said that the team understands the cultural background of residents and how this impacts on their daily lives. Staff files showed that all the necessary recruitment checks are in place, including proof of identification, references and a photograph. One member of staff had a Criminal Records Bureau disclosure from 2004 carried out by their previous employer. This should be renewed with the current provider as the counter signatory. Supervisions take place regularly and staff said that they feel supported in their roles. The recording of supervisions could be improved to ensure that any decisions and actions are clearly recorded, together with timescales for review. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 19 Two staff have completed NVQ3 training and two more are currently undertaking it. Recent training for staff includes food hygiene, health and safety, disengagement and abuse. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a good understanding of the needs of residents, however, recording systems must be improved. EVIDENCE: The manager is a Registered Mental Nurse and has been at the home for several years. He has a good understanding of the needs of the residents who live there. Staff said that they feel supported by the manager. The registered provider carries out monthly monitoring visits as required. Copies of the reports are kept in the office. There is no formal system in place for reviewing the quality of care at the home. However, resident meetings Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 21 showed good involvement from residents, including ideas for improving the home, for example a request for new crockery. Records kept at the home were disorganised and sometimes difficult to find. The system for maintaining records and files must be reviewed to ensure they are in good order and secure. Records are kept of health and safety checks on the building. These were all up to date. The fire system was inspected in December 2006 and a fire safety risk assessment is in place. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 3 X Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 YA6 Regulation 15 Requirement The registered persons must ensure that all residents have a plan of care which includes individualised goals and how these will be met by the home. The registered persons must ensure that an up to date copy of the local POVA procedures is obtained. The registered persons must ensure that the panel at the end of the bath is fixed and that the plug socket in the lounge is replaced. The registered persons must ensure that a formal system is implemented to review the quality of care at the home. The registered persons must ensure that the system for maintaining records and files is reviewed. Timescale for action 31/03/07 2 YA22 13(6) 28/02/07 3 YA24 23(2)(b) 28/02/07 4 YA39 24 31/03/07 5 YA41 17 31/03/07 Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 24 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 4 Refer to Standard YA6 YA23 YA24 YA36 Good Practice Recommendations The registered persons should ensure that care plans and risk assessments are typed up. The registered persons should ensure that residents are offered professional financial advice. The registered persons should ensure that the kitchen is refurbished. The registered person should ensure that the recording of supervisions is improved to include decisions and timescale for review. Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Trevelyan Road DS0000029318.V324212.R01.S.doc Version 5.2 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. 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