CARE HOMES FOR OLDER PEOPLE
Warren The 84 Coombe Road Croydon Surrey CR0 5RA Lead Inspector
Margaret Lynes Unannounced Inspection 19th January 2006 1:15 X10015.doc Version 1.40 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 Warren The DS0000025856.V279412.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 Older People. 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. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Warren The Address 84 Coombe Road Croydon Surrey CR0 5RA 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 8688 7022 020 8688 7022 Mr James Emmanuel Kwabena Safo Mrs Bernadette Joan Redmond Care Home 18 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (0) of places Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow one specified resident under the age of 65 to be admitted. 8th August 2005 Date of last inspection Brief Description of the Service: The Warren is situated in a pleasant residential area of Croydon, opposite a Tramlink stop and overlooking Lloyd park. The house itself is well named, with the two double bedrooms being situated in the turret of the home, and the top floor comprising of four single rooms each of intriguing dimensions. The accommodation comprises of the aforementioned two double rooms and fourteen single. There is a large lounge on the ground floor, which leads into the conservatory dining area. Part of the conservatory can be curtained off to provide a more secluded space for meetings. There is a second, smaller conservatory, which serves as the designated smoking lounge. The home has an extremely attractive garden, the feature of which is a large fishpond. The stated aim of the home is for it to be run to a very high standard and to give effective environmental, physical and psychological care for the elderly, incorporating quality job satisfaction and status to the people it employs. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of this visit was to determine if the manager had taken action with regard to the three requirements and one recommendation that were made following the previous inspection. The inspection took place over the course of several hours, which allowed time to be spent talking with service users. What the service does well: What has improved since the last inspection? What they could do better:
While no requirements have arisen from this visit, and it was noted that refurbishment of parts of the home was underway, the Inspector felt that this refurbishment had been a long time in coming, and the proprietor should have given earlier consideration to ensuring that the premises were kept in good condition. It is recommended that in future, more prompt action is taken when areas of the home need to be refurbished. This being said however, it was pleasing to observe the improvements that had been recently made. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 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. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 As two new service users had been admitted since the last inspection visit the opportunity was taken to examine their files. From the information they contained it was felt that sufficient detail was being obtained pre-admission so that both the service users and the staff team could be relatively confident that assessed needs could be met. EVIDENCE: Both of the aforementioned files contained a pre-admission assessment carried out by the home manager. One also contained an assessment by the placing authority. These had then been supplemented by care plans and risk assessments. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 The opportunity was taken to sit and talk with four of the service users. From their comments the Inspector was satisfied that they were happy with the service provided, and that it was meeting their needs. EVIDENCE: All of the service users who were spoken with commented positively about the home. They were satisfied with all aspects of the service – their accommodation, the food (with one exception) and the care. Just one raised a query, which related to a wish to be provided with more fresh fruit and vegetables. This request was relayed to the manager. She was already aware of this as the service user had raised the same issue on a recently carried out quality assurance survey. Arrangements were being made for the service user to have a bowl of fruit in her bedroom, while the request for more vegetables had been passed on to the cook. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit (however see comments in summary section of this report). EVIDENCE: Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed on this visit. EVIDENCE: Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 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 and 38 The home has in place a quality assurance system, which enables the management to identify any areas where the service is sub-standard and then take action to improve it. This means that the best interests of the service users are being promoted. Two issues were identified re health and safety at the last inspection. Action has been taken to improve matters which means that the welfare of both service users and staff is being promoted and protected. EVIDENCE: At the last inspection it was not felt that the quality assurance system was satisfactory, as a number of audits were overdue. This has been rectified, and on this visit, the audits, including recent quality assurance surveys of the
Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 15 service users, had been carried out as planned. A new section has been added to the aforementioned surveys, so that staff now have a space to write more detailed feedback from residents, and to also write down what action has been taken in response to any issues raised. The previous inspection led to requirements being made about health and safety risk assessments, and the need to ensure that fire drills were carried out on a quarterly basis. Both of these requirements have been met – drills are now being carried out at regular intervals, while the health and safety risk assessments have been updated. Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 17 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. 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. Refer to Standard Good Practice Recommendations Warren The DS0000025856.V279412.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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