Inspection on 01/09/05 for Wheathill Road, 19

This inspection was carried out on 1st September 2005.

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 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

Wheathill Road, 19 16/11/07

Wheathill Road, 19 26/09/06

Wheathill Road, 19 25/01/06

Wheathill Road, 19 07/12/04

Wheathill Road, 19 04/05/04

Wheathill Road, 19 20/11/03

Wheathill Road, 19 01/09/03

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 Wheathill Road 19 Wheathill Road Penge London SE20 7XQ Lead Inspector Rosemary Blenkinsopp Announced 1 September 2005 08.15 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 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 Stationary 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. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wheathill Road Address 19 Wheathill Road, Penge, London, SE20 7XQ Telephone number Fax number Email 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 8659 7425 Community Options Limited Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 5 adults of either sex with a mental disorder (within the category MD). Date of last inspection 07/12/04 Brief Description of the Service: The home is a large house located in a residential area of Penge. The facility is part of the Community Options group, which operates the home, whilst Hyde Housing owns the building. The home is for five residents who have long-term mental health problems. The main purpose of the home is rehabilitation into the community, with residents developing the skills for more independent living. Residents are encouraged and supported to be independent in all activities of daily living. In addition integration into the local community and accessing local services including health provision is promoted. The home has its own staff team with a manager and deputy heading up the team. Senior management and personnel are provided through the head office of Community Options. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted as an announced visit of which the home was notified several weeks in advance. In preparation for the inspection the notices were on display throughout the home. The pre inspection information had been completed though not received by the CSCI; this was received after the inspection. The inspector met with the staff on duty, including the temporary manager. The residents all met with the inspector either as a group or individually. A tour of the premises was undertaken including some bedrooms and all communal areas. Records including care plans, medication charts, health and safety documentation were all inspected. The findings of the day were positive and this was reinforced by comments received from residents. What the service does well: What has improved since the last inspection? What they could do better: The care plan documentation needs further improvement and with a new format being developed, it is imperative that all aspects of residents’ needs, risks assessments and supporting information are included and comprehensively completed. The documentation must be user-friendly with information easily accessible to both staff and residents. Please contact the provider for advice of actions taken in response to this Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5. Residents are provided with sufficient information on which to base their decision regarding placement. Limited availability in respect of this type of accommodation means that choice is limited. EVIDENCE: The Statement of Purpose was inspected. It contained all items as required under Schedule 1, Care Standards Act 2000. The Statement of Purpose will need to be amended once the new manager has been appointed, as this section is incorrect. It was noted that one resident is now 70 years of age; the registration category is up to 65 years. In order that this resident can stay in the home a variation needs to be sought from the CSCI. Please see requirement 1. The admission process takes place over a period of time to allow the prospective resident time to accustom themselves with the staff and other residents and visa versa. The last resident to be admitted had been to visit the home for a day period. His relatives had visited the home and there had been assessments conducted by a manager from a Community Options facility. A standard assessment form had been completed. This document was not available to view and needs to be forwarded to the CSCI. In addition, information had been received from members of the multi-disciplinary team involved with his care. The resident was only in the home for four days before Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 9 he needed to be admitted back into hospital. He has an allocated key worker who has maintained contact during his hospital admission. Prospective residents complete an application form and once admitted Terms and Conditions are issued. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 standard(s) 6,7,8,9,10 The care plans were not sufficiently completed to reflect the residents’ needs, choices or the associated risk assessments. Staff must have information, which is current, on which to base the residents’ care needs. The intervention section of care plans was limited in content and would not address the identified problem. EVIDENCE: The care plan of the resident recently admitted was viewed. It was the standard Community Options format. There was a Care Programme Approach review in the care plan but this was dated March 2003. This document was comprehensive in content including physical and mental health issues with supporting risk assessments although it was difficult to assess if this information was current. The home itself did not have a care plan in place or associated risk assessments, which included those for fire risk, missing persons, violence and aggression. It was evident that the resident had only spent a short period in the home, however, it is essential that there is information in respect of all identified needs in the initial period. Staff must be able to access care plans which comprehensively details the actions and interventions required by staff. Please see requirement 2. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 11 All information is retained in the staff office. Two residents deal with their own finances. Records relating to financial transactions were inspected and audited against receipts/monies and found to be correct. Some transaction were documented in pencil: all records should be in pen. Please see recommendation 1. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 standard(s) 11,12,13,14,15,16,17. Residents living in this community setting experience a lifestyle which is individual to their needs, whilst developing their daily living skills to promote more independent living. EVIDENCE: Three residents were spoken to in the smoking area and one in her bedroom. One resident remains in hospital. Residents described attending centres such as MIND in Beckenham and Stepping Stones. Several residents go out for coffee and use the facilities locally. Family and friends are free to visit the home at any time. At other times the residents spend time in the home doing their chores or socialising with the other residents and staff. A group holiday had been planned although this had been cancelled at the instigation of the hotel. Another holiday will be planned. Days out have been organised, with more planned. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 13 Residents have allocated key workers who co ordinate their care. Key workers and residents agree care plan goals with where possible time frames. The residents’ access all the facilities provided within the local community including health care and leisure activities. All residents can go out unaccompanied. Individual missing persons’ risk assessments are in place for each resident. Residents’ meetings are held monthly and minutes circulated. Residents shop, prepare and cook their own meals with staff supervision. Healthy eating is encouraged and weight records are maintained. One resident spends the majority of her time in her bedroom. Members of her family supply her with food. She tends not to engage in any of the activities available. So far the home has been unable to facilitate any programmes to promote rehabilitation, which is in conflict with the aims and objectives of living in Wheathill Road. This placement is under discussion. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18,19,20. Health care is provided through the community provision, which is appropriate for this group of residents. EVIDENCE: The residents in this home must be mobile and have a level of independence in respect of personal hygiene as there is no lift in the home or manual handling aids. Those residents who are unable to manage stairs etc would be reviewed with a view to an alternative placement. Residents access all health care in the community. The GP provides District Nursing support to one resident. The accident book is Data Protection Compliant and reports are stored securely. Four residents have required referral to the accident and emergency department. Residents have access and support from the multi disciplinary team and have a named Responsible Psychiatrist under the Care Programme Approach (CPA). All five residents are under the enhanced level of Care Programme Approach. Reviews are undertaken on a regular basis and care plans implemented under the CPA. The home promotes independence including self-medication; currently one resident is self-medicating. He is supported by staff who check his medication and monitor compliance. All medications are recorded including those received into the home and those returned to the pharmacy. Medications, which were audited, were found to be correct. Homely remedies are signed by the GP Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 standard(s) 22,23. Concerns and complaints are taken seriously in this home, with external investigations facilitated where appropriate. EVIDENCE: The CSCI has received no complaints regarding this service. Records indicated there have been no complaints registered internally. Residents themselves were aware of who they should complain to, most stating the manager or their key worker. One staff member with whom the inspector met was aware of what constitutes abuse and the action to be taken. He stated that he had received training on this topic, and records indicted that he was due to attend a further training session 13/12/05. The complaints information was available in the hall and included in the Statement of Purpose. Any complaint would be investigated either by the manager or senior staff from Community Options Head Office. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 standard(s) 24,25,26,27,28,29,30. The environment is suitable for those residents who are fully mobile, however with the ageing population in the home, residents’ suitability must be kept under review. EVIDENCE: The communal areas and some bedrooms were inspected. All communal areas were clean, tidy and free from hazards. The dining room had been re decorated March 2005. The home is maintained in a domestic style with comfortable furniture and fittings. There is one room which is smoking; the rest of the home is no smoking. This can be sometimes difficult to implement. All bedrooms are single without en suite facilities. The individual bedrooms were personalised and residents have their own door keys. Furniture and fittings are as decided upon by the individual resident. Radiators are not covered although these are part of the environment risk assessment. Toilets are provide throughout the building and there are three bathrooms. There is a large fully equipped kitchen with separate laundry equipment. Residents are provided with cupboard and fridge/freezer storage space for their foodstuffs. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36. Staff are provided with sufficient support, supervision and training to undertake their roles in a competent manner. EVIDENCE: Currently there are five staff in post with one full time vacancy. The manager is in the home temporarily, due to transfer to anther Community Options facility September 2005. The vacancies are currently being advertised. Staff vacancies are covered either by regular staff doing extra shifts or the use of regular bank staff, and on rare occasions agency staff. On call systems are in operation for out of hours emergencies covered by senior managers. The deputy manger spoke with the inspector. There was discussion regarding his key resident with which the inspector had met during the inspection. This information was cross-referenced with the resident’s care plan. The staff member demonstrated a good knowledge of the residents needs and on going support that he needed. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 18 The Deputy Manager completes his Registered Manager’s Award September 2005. He confirmed on going training identifying a number of courses which he had attended relevant to the resident group. In addition he had completed first aid, manual handling, health and safety and basic food hygiene. He confirmed that one-to-one supervision was on a monthly basis by a senior staff. Staff meetings are held monthly. The manager confirmed on the pre inspection questionnaire that all staff had completed NVQ2 and first aid training. All new staff complete the TOPPS induction and the three-day company orientation. Staff personnel file are not retained in the home. It had been agreed with the pervious regulating authority the NCSC, that these could be retained at the Head Office in Bromley. The inspector plans to inspect these 14 October 2005. Two CRBs were located in the home including that of the temporary manager, both were satisfactory. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41,42. The home is managed in an open and inclusive style, where health and safety are taken seriously, both in the everyday practices and the ongoing maintenance of the building and equipment. EVIDENCE: The permanent manager left June 2005. Mr Barry has been managing the home temporarily. Mr Barry will be moving to another Community Options home September 2005. He is starting the NVQ 4, 19 September 2005. He has a background in care, and health and safety, and is very orientated to potential risks. A selection of health and safety records were inspected and found to be satisfactory. Fire equipment is serviced on a contract basis. Fire alarms and emergency lighting are tested at appropriate intervals. The annual fire risk assessment had not been reviewed since 4/2/04 this needs to be updated. Please see requirement 3. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 20 Hot water temperatures are recorded. Some were written in pencil and indicated that the outlet temperature was above 43oc. In the event that hot water temperatures are higher that 43oc, the action taken to prevent injury, needs to be stated. The first aid boxes were appropriately stocked. In respect of quality assurance issues in house staff and residents meetings are held and minuted. There is information relating to complaints and suggestions for residents and visitors. Community Options conduct annual staff and residents surveys. The information relating to the responses is collated and circulated, with action taken where needed. Regulation 26 visits are now being conducted monthly unannounced and reports available. Recent reports were seen however there was a gap prior to these dating back to September 2004. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wheathill Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 x 3 2 x G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 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 1 Regulation 4 Requirement The Registered Provider must ensure that the Statement of Purpose includes all information as detailed in Schedule 1 which is accurate. All residents must be within the registration and age range.Variation must be sought for the resident above the age of 65, which is stated within the registration category. The Manager must ensure that care plans, risk assessments and all supporting documentation is in place, current and kept under review. The Manager must ensure that the fire risk assessment is conducted on an annual basis. Action must be taken when hot water temperature are above the 43o c limit. Timescale for action 31/12/05 2. 6 15 30/9/05 3. 42 23 30/9/05 Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 23 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. Refer to Standard 7 Good Practice Recommendations The Manager must ensure all records are retained in pen. Wheathill Road G51-G01 s6907 Wheathilll Rd AI v232238 010905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH 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. 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