Inspection on 23/01/06 for Vancouver Road, 23

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vancouver Road, 23 06/07/07

Vancouver Road, 23 20/12/06

Vancouver Road, 23 13/05/05

Vancouver Road, 23 22/11/04

Vancouver Road, 23 24/06/04

Vancouver Road, 23 06/02/04

Similar services:

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Vancouver Road, 23 Forest Hill London SE23 2AG Lead Inspector Lisa Wilde Announced Inspection 23rd January 2006 10:00 Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 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 Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 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. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Vancouver Road, 23 Address Forest Hill London SE23 2AG 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) 0208 6993762 vancouver@regard.co.uk The Regard Partnership Limited Mr Marc Anthony Baker Care Home 8 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Eight residents, of whom four may have both a learning disability and a mental disorder (dual diagnosis) 13th May 2005 Date of last inspection Brief Description of the Service: Vancouver Road provides a care home to a maximum of eight women and men with mild to moderate learning disabilities, who might also have other support needs. A maximum of four service users might also have a diagnosis of a mental disorder. The overall aim is that of providing a specialist service in a nurturing and stimulating environment, which would enable users to develop or achieve independent living skills within a community setting. The home aims to achieve this through service users plans, developed and regularly reviewed by the service user with support from staff, advocates, local specialist teams and the placing authority. The plans are to provide a structure within which to address individual needs, choices and aspirations, backed by risk assessments, to assess the appropriate degree of support required so that risks are minimised. The home states that staff have relevant experience in the field of learning disability and mental health. The provider is a company: The Regard Partnership Ltd. who provides other residential homes and supported living in England and Wales. The statement of purpose says that the two directors are qualified nurses with experience in learning disability and mental health. The day-to-day running of the home is delegated to a manager, who leads a team of staff. The premises are a semi-detached house, with single bedrooms on three floors and a large garden. The home is not suitable for people who cannot manage stairs. The area is served by public transport, has a selection of shops and other civic amenities. At the time of this inspection there were no vacancies. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over one day in late January 2006. The inspection had been announced to make sure that the new Registered Manager was there as he had not been in post at the last inspection. The inspector spoke with service users who were in the home, staff and the Registered Manager, examined records and policies and toured the building. The inspector found that all the requirements and recommendations made at previous inspections had now been met and found only a few more at this inspection. Generally service users said they were very happy at this home. One service user was feeling particularly anxious so understandably didn’t want to talk to the inspector for too long. Other service users said that they were allowed to live their lives as they chose and they did everything they wanted to do. They said they went out in the local area and knew it very well. One service user talked of their partner and how they were planning to move on from the home eventually. Service users said staff were helpful and nice and they liked their rooms. What the service does well: The standards assessed at this inspection showed that the home makes sure that: • potential service users have the information they need to decide where to live and current service users know what they can expect from staff and the home. • prospective service users have their needs and any risk assessed by competent staff and the home decides whether they can meet those needs. • service users can visit the home for a series of trial stays to allow them to get used to staff, other service users and life at the home before they decide to move there permanently. • care plans are drawn up that are based on the initial assessment of service users that show how staff will meet the needs of the service users and minimise or manage any risks. • staff consistently operate the systems in place to effectively store and administer medication. • service users are asked about their wishes in the event of serious illness and death and these issues are included in their care plans. • complaints are generally recorded, investigated and taken seriously. • the home is clean, hygienic and comfortable throughout. • the home is achieving the targets for numbers of NVQ qualified staff. • it is now clear what training expectations there are of each role within the home Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 6 • • • the recruitment procedures are now robust and effective. the new Registered Manager has the skills and experience to effectively manage the home. the service users are protected by the health and safety systems in the home. 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. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 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 Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 4 The Service User Guide is clear and thorough and given to all potential new service users which means that they have the information they need to decide where to live and current service users know what they can expect from staff and the home. Prospective service users have their needs and any risk assessed by competent staff and the home decides whether they can meet those needs. This means that service users know that the home has decided that they can offer them a useful service prior to them moving to the home. Service users can visit the home for a series of trial stays to allow them to get used to staff, other service users and life at the home before they decide to move there permanently. EVIDENCE: There was a previous requirement that the statement of purpose and service users’ guide to be reviewed to make certain that the information is up to date and includes all that is required by the relevant standard and regulations. This work had been done and the documenrs now met the standards. The process for the assessment and admission of service users was the same as at the last inspection. Two service users have moved inte the home since the last inspection and both had undergone full assessments of their needs and any risks prior to them coming to the home and care plans had been drawn up Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 9 based on these issues. Service users visit the home for a series of trial stays before they move to the home permanently. These trial visits depend on how the service user and staff feel things are going and will vary from person to person. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 & 10 Care plans are drawn up that are based on the initial assessment of service users that show how staff will meet the needs of the service users and minimise or manage any risks. Plans are forward looking and focus on maximising independence, developing service users skills and allowing them to reach their goals. Although the home has the facilities in place to store service user information securely, on the day of the inspection some information was left in the lounge with other service users. EVIDENCE: The inspector looked at some of the care plans for service users, which had been revised since the last inspection. The number of documents have now been reduced and made clearer. All areas of each service user’s life had been assessed with the service user and any areas of need or risk had been identified and plans put in place to minimise risk or meet goals. Staff actions were in place but the language of the care plans was that of staff and not of the service user, in some cases the language was complicated. (See Requirement 1) Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 11 Although care files were stored in the staff office at the front of the ground floor, during the course of the inspection some service user information was left in the lounge with service users. (See Requirement 2) Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed At the last inspection, the following judgement was made :Residents were supported to lead meaningful lives, appropriate to their peer group, aspirations and cultural preferences and norms. Staff endeavoured to ensure that residents had opportunities for education and training, work, integration into community life, leisure activities and to have a real say and influence about the running of the home. EVIDENCE: Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21 Systems are in place to effectively store and administer medication and staff follow these systems consistently which means that service users who are not taking their own medication, are protected by how the home manages their medication. Service users are asked about their wishes in the event of serious illness and death and these issues are included in their care plans which means that should something happen staff will know beforehand what they want and will not have to ask them or their families at a potentially difficult time. EVIDENCE: There was a previous requirement that all staff who administer medication must have formal training and to read the home’s medication policy. This had now been done and records were maintained of all staff who had attended the training. There was a previous requirement that a list of designated staff (permanent and bank/agency), who may administer/handle medication must be maintained. This was now done. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 14 There was a previous recommendation that the providers policy on medications is consistently followed or reviewed. The evidence from the files showed that this now occurs. The inspector checked the medication stocks and records and found no further problems. The home has a policy and procedure for when service users die or are ill and care plans showed that these issues are raised with service users so that staff know what they want should they die while living at the home. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Complaints are generally recorded, investigated and taken seriously which means that service users feel that their concerns are listened to and acted upon by staff. EVIDENCE: At the last inspection, a recommendation was made that management continues to review with residents, relatives, supporters, staff and external professionals, how best residents can be enabled to express concerns, if any. The Registered Manager said that he has continued to consult with service users. This issue is more fully discussed under Standard 39. The complaints record shows that complaints are investigated and taken seriously but no record is made of the date the complaint is closed and whether the complainant was happy with the outcome. (See Requirement 3) Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The home is clean, hygienic and comfortable throughout. EVIDENCE: There was a previous requirement that the heavily stained carpets in the dining room and hallway must be replaced. This had been done. The communal areas of the home were clean and hygienic and decorated in ahoimely manner. Service users all said they were happy with their rooms apart from a couple of small replacements that were needed that staff were already aware of and in the process of addressing. The rooms that were seen during this inspection were personalised to individual service users tastes. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 17 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 & 35 The home is achieving the targets for numbers of NVQ qualified staff, which means that service users are receiving support from a qualified staff team. Because of the new training audit it is now clear what training expectations there are of each role within the home but there are training gaps, particularly in the areas of statutory training which means that service users are not receiving support from a fully trained staff team. The recruitment procedures are now robust and effective with the required checks and documentation being received back before staff begin work. This means that service users are protected from harm by the organisation being as sure as possible that staff are who they have said that they are and have checked their previous work experience and references. EVIDENCE: Eighty percent of staff either hold or are undertaking the NVQ Level 2 or 3 in Care. There was a previous requirement that the range of skills and qualifications or training, which the provider consider necessary in the staff team, must be clearly stated. The Registered Manager has conducted a full audit of all the training that staff have undertaken and compared this against a list of all required training for all posts. These lists highlighted that there are significant Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 18 gaps in certain areas of the statutory training required by staff. (See Requirement 4). There was a previous requirement that all statutory checks, to ensure suitability of staff, must be conducted and inform the decision to appoint. In particular all previous work and education history must be obtained and any gaps explored. The application form for employment has been altered and only one member of staff has as yet completed this new form. Evidence from the files showed that the recruitment procedure would now meet the standards and a full work history would be obtained (as opposed to the last few years which had been previous practice). As a matter of record the longer term staff who have not completed the new application form should now provide the organisation with their full work history. (See Recommendation 1) Currently the organisation does not inform applicants what (if any) criminal offences may be accepted for each post and how they will decide the relaevance of any offences. (See Recommendation 2) Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 19 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, 40 & 42 The new Registered Manager has the skills and experience to effectively manage the home. The home does not effectively gather the views of service users, their families and other stakeholders and does not develop an annual plan, which shows how the home will improve based on those views. This means that the organisation cannot fully show that the home is being run in the best interests of the service users. Although policies are up-to-date and to a point effective and useful, staff and service users are not involved in their development, which means that they are not as useful and relevant to the service as possible. The service users are protected by the health and safety systems in the home and by staff operating these systems consistently. EVIDENCE: Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 20 The Registered Manager has been a manager at other Regard Partnership service before taking this post and has worked in mental health and substance misuse services since 2001. He is about to undertake the Registered Managers Award NVQ Level 4. Throughout the inspector he showed his awareness of the needs of service users and how staff should attempt to meet those needs. The inspector discussed with the Registered Manager the systems for gathering service user views and those of their families and other stakeholders. Currently there are no surveys conducted and little external views of the service sought. The organisation does complete the monthly monitoring visits as required by the standards. There is no annual development plan for the home, based on the views of service users and their families. The home seeks the views of service users through keywork sessions and house meetings, which occur six weekly. (See Requirements 5 & 6 and Recommendation 3) The inspector viewed some of the home’s policies through the inspection and found them to be useful and clear. The policies are issued from senior staff in the organisation and currently there is no procedure for staff and service users (where relevant) to be involved in the development of policies for the home. (See Requirement 7) All the health and safety records and certificates were checked and all were in order and up-to-date. On the tour of the building no health and safety issues were noted. Service users and staff said that there were no problems with the maintenance of the home that they were aware of. Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 21 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 3 X 2 2 X 3 X Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 22 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 YA6 Regulation 15 Requirement The Registered Manager must ensure that service users are fully involved in writing their care plans and that they are written in the most effective language possible to make sure all service users understand and agree with them. The Registered Manager must ensure that service user information is handled and stored securely at all times. The Registered Manager must ensure that the date of the closure of complaints is recorded along with whether the complainant was satisfied with the outcome. The Registered Individuals must ensure that all staff receive the required statutory training. The Registered Individuals must ensure that various effective systems are in place for regularly gathering the views of service users, their families and other stakeholders on the service they receive. The Registered Individuals must ensure that an annual DS0000025649.V274398.R01.S.doc Timescale for action 31/05/06 2. YA10 17 (1) (b) 28/02/06 3. YA22 22 31/03/06 4. 5. YA35 YA39 18 (1) (c) (i) 24 30/06/06 31/07/06 6. YA39 24 31/07/06 Vancouver Road, 23 Version 5.1 Page 23 7. YA40 24 development plan is in place that shows how the service aims to improve over the coming year based on the views of service users, their families and other stakeholders. The Registered Individuals must ensure that a system is devised that ensures staff are fully involved in policy development and service users are offered the opportunity to be involved in policy development where relevant. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA34 YA34 Good Practice Recommendations The Registered Individuals should ensure that all staff complete a full employment history. The Registered Individuals should ensure that there is a written policy and procedure for establishing which criminal offences (if any) are acceptable for each post within the home and that potential applicants are made aware of this policy and procedure. The Registered Individuals should consider using a professionally recognised quality assurance system. 3. YA39 Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 24 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 Vancouver Road, 23 DS0000025649.V274398.R01.S.doc Version 5.1 Page 25 - 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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