Inspection on 07/10/05 for Wimbourne House

This inspection was carried out on 7th October 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wimbourne House 22/01/08

Wimbourne House 01/03/07

Wimbourne House 16/05/05

Wimbourne House 17/08/04

Wimbourne House 01/04/04

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 Wimborne House 16 Wimborne Road London N17 6HL Lead Inspector Mr Teferi Degeneh Unannounced Inspection 7th October 2005 10:25 Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wimborne House Address 16 Wimborne Road London N17 6HL 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 8493 9947 020 8801 0620 Mr Kwame Adusei Mr Kistnasamay (Chris) Thandrayen Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2005 Brief Description of the Service: Wimborne House is located in a residential area close to Bruce Grove where there are a range of local shops and easily accessible public transport. The home is registered to provide residential care for three people with Mental disorder, excluding learning disability or dementia. The registered provider, Mr Kwame Adusei, owns a number of similar small homes in this area. The home is an ordinary house, on a domestic scale and fits in well with the surrounding area. It has three bedrooms, a separate toilet room and one bathroom, with a shower over the bath. There is a shared lounge, kitchen and dining area and a rear garden. The home has four care staff, two night staff, a part time domestic staff and a manager. Staff are on duty on a twenty four hour basis. The organisation’s brochure states that it specialises in supporting service users who may have a forensic history or may be on the supervision register and that the aims are to respect the resident’s privacy and dignity, maintaining and promoting personal identity and the right to choose. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection for the year and was conducted over a period of 4 hours, beginning at 10:30am and concluding at approximately 2.30pm. The manager, Mr Kistnasamay (Chris) Thandrayen, was present throughout the inspection The inspection activity undertaken included a tour of the building, the examination of service users files including care records, the examination of health and safety records, the viewing of staff rotas and discussions with one service user. What the service does well: What has improved since the last inspection? What they could do better: The registered person needs to ensure that the back door must be fitted with an appropriate locking system that meets the fire safety requirement. The gas boiler and heating system need to be serviced and certificates are made available for inspection. It is required that service users are consulted about the quality of the services and facilities. The registered person must formulate an action plan as part of the consultation process and ensure that the outcome of this together with the action plan is made available to the service users and the Commission for Social Care Inspection. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 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. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, and 4 There is a satisfactory system of admission enabling new service users to visit the premises, see the facilities and meet existing service users before making a decision to accept an offer of admission. Service users are confident that their admission is based on the outcome of their assessment and that the home can meet their needs. EVIDENCE: No new service user has been admitted since the last inspection. Three service users’ files, which were assessed, contained evidence of assessments completed by health professionals and social workers. The registered person said prospective service users are also assessed by the home in order to determine whether or not the services and facilities available would meet their needs. The registered person stated that new service users are encouraged to visit the home and have overnight stays before their admission. A service user spoken to confirmed that they had visited the home before their admission. The home’s referral and admission policy states: “All referred clients will be assessed and a decision made within 1-2 weeks of referral…. Before admission all potential residents will be requested to visit the home, meet the staff and meet the residents. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Robust systems of risk assessments are in place to ensure that possible risk areas are identified and appropriate actions are taken to safeguard the health and safety of service users. Service users have benefited from the regular reviews of their care plans and their ability to spend their money as they wished. EVIDENCE: All service users’ files were examined. These showed that the home reviews care plans on a monthly or bi-monthly bases depending on service users’ needs. It was evident from the assessed care plans that service users have been involved in the review of care plans. Reviews of care plans are also undertaken annually and attended by health professional, social workers, service users and care staff. An activities’ co-ordinator has been employed by Wimborne House, the Company which runs the home, and comes to the home once a week to facilitate activities for service users. Service users’ interests and their involvement in various activities have been recorded in their files. Periodic progress summaries are written and kept in each service user’s files. In a Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 10 discussion, a service user said staff have talked to them about activities but they preferred to do their own things independently. Discussions with the registered person and a service user indicated that service users are able to manage their finances. However, the home assists service users with application for benefits. All the service users are able to travel independently to shops, cafés, post offices and recreational places. A service user spoken to said they have bedroom keys and are free to decide when to go to bed and when to get up. The files of service users contained evidence of current risk assessment. The outcome of risk assessment of some service users means that the registered person keeps records of times they leave and return to the home, and the whereabouts when they are out. The referral and admissions policy of the home requires the registered person to “conduct a further risk assessment in relation to the suitability of the resident”. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14,15, and 17 The arrangements for service users to access social and leisure activities are satisfactory and service users’ needs with respect to these activities are met. Service users feel that they live in a home where their privacy and dignity are respected and where they have right to see or speak to families and friend in private. Satisfactory progress has been made in regards to the quantity and variety of meals provided. Service users are satisfied with the arrangement of the meals they are provided with. EVIDENCE: As mentioned above, there is an activities co-ordinator who comes to the home to support service users with day and leisure activities. Service users’ files have evidence of activities service users undertook with support from the activities co-ordinator. Discussions with the registered person and a service user demonstrated that service users regularly go to cafés, restaurants, public houses and cinemas. The registered person said service users have been supported to go on trips to the seaside. A service user said in a discussion that they have been abroad on a holiday and they are again in the process of Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 12 organising a similar trip to visit families and friends. It was evident from records and discussions with the registered person and a service user that service users are able to visit friends. A service user was observed using the home’s telephone to talk to their social worker in private. A pay telephone is also provided in a room where service users can sit on a chair and privately talk to friends. The registered person confirmed that all service users are registered to vote and some service users are able to go to places of worship. The home has a non smoking policy in communal areas. As mentioned earlier, all service users have bedroom keys and can choose when to be alone. A service user spoken to said the staff are good and they talk to them appropriately and always knocked on the doors and waited outside to seek permission to enter bedrooms. At the last inspection a requirement was made for the registered person to consult service users and provide them with suitable, wholesome and nutritious food which is varied and properly prepared and available at such times as may reasonably be required by service users. The evidence seen confirmed that the requirement has been complied with. Each service user is supported to identify list of food items they would like to have. The home then does food shopping for two service users to keep and cook individually at he time of their choice. One service user does their own shopping. Two of the service users have freidge/freezers in their bedrooms and there are two more fridge/freezers in the home. On the day of the inspection there were large quantities of milk, frozen and fresh food items and fruits in the home. A service user spoken to said they are happy with the arrangents implemented in respect of meals. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 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): 19, and 20 The systems for the administration of medication are good with clear arrangements being in place to ensure service users’ medication needs are met. There are satisfactory systems in place to ensure that service users receive appropriate health care. EVIDENCE: Medication is administered by the staff. Dossette boxes and medication administration sheets were checked and were found to be in order. Medicines are kept in a locked cabinet in the office. All service users are registered with their own general practitioners. It was evident from appointment letters, the home’s diary and a discussion with the registered person that service users had appropriate health care. A service user said the home has supported them to receive appropriate medical advice and support from health professionals regarding their travel abroad. The files seen showed that service users’ health is checked regularly. The home has a smoking policy and this is discussed with service users. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 14 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, and 23 Service users are reassured by their knowledge of the home’s complaints procedure. The registered provider has satisfactory policies, procedures and practices, which ensure that service users are protected from abuse EVIDENCE: No complaints have been recorded since the last inspection. The home has a complaints procedure with the address of the CSCI local office. A discussion with a service user and the minutes of service users’ meetings indicated that service users are aware of the home’s complaints policy and they know how and who to complain to if they have concerns. There are satisfactory policies and procedures on the protection of vulnerable adults from abuse (POVA). The registered person has obtained a copy of the placing authority’s policy and procedures of protecting vulnerable adults from abuse and this is reflected in the home’s own POVA policy. It was evident from a discussion with the manager and the staff files that the staff have attended training on abuse. A service user confirmed in a discussion that they have a bedroom key and that the staff always knocked on the doors for permission to enter bedrooms. A service user said staff treated them with respect and dignity and they are happy living at the home. All service users look after their own money but the home supports them with their benefits. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 15 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, and 30 The location, size and cleanliness of the home are good enabling service users to feel that they live in a comfortable and homely environment. EVIDENCE: The registered person has redecorated all rooms and has replaced the malfunctioning bed for a service user as required at the last inspection. The loose television aerial behind the television set in the lounge has also been fixed since the last inspection. As mentioned above, the home has a smoking policy which service users are clear about. All parts of the premises were clean, tidy and free from offensive odours on the day of the inspection. The registered person said a part time domestic person cleans communal rooms and service users are responsible for cleaning their bedrooms. A service user spoken to said they are able to clean their bedroom. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, and 35 The staffing level and the training programmes provided at this home are satisfactory to meet service users’ needs. The recruitment procedures of the home are satisfactory. EVIDENCE: The home has four care staff, two night staff, a part time domestic staff and a manager. An activities co-ordinator and training organiser are also employed by the company which owns this home. The registered provider and a care coordinator visit the home daily to provide management support as required. The registered person said service are quite independent in terms of personal care, social care, house tasks, cooking, cleaning and leisure activities. Records in the files showed that the activities co-ordinator comes to the home on a regular basis to support service users with social and leisure activities. The services of a part time cook has recently been stopped as service users have become more independent in the preparation of their meals. The rota, which was examined, and a discussion with the registered person indicated that there is one member of staff on shift at all times and that additional staff are called in from a pool of staff employed by the Company that owns this home. It is evident from staff files that the staff have attended a range of training programmes relevant to the purposes of the home. The registered person confirmed that three care staff have completed a care qualification equivalent to NVQ level 2. As mentioned earlier there is a training co-ordinator with a responsibility of identifying and providing training programmes for the staff. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 17 No new member of staff have been employed since the last inspection. All staff currently employed have satisfactory CRB’c and two written references in their files. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 18 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): 39, and 42 Despite the cleanliness of the home and satisfactory fire policies and procedures, service users’ health and safety remains at risk due to lack of gas boiler safety checks and lack of appropriate locking system on the back door. The systems for service user consultation are poor with little evidence that service user views are sought or acted upon. EVIDENCE: Risk assessments have been completed for each service user. Discussions with the registered person and a service user indicated health care advice has been obtained from relevant professionals regarding a service user who was due to travel abroad for a holiday. It was evident from records that satisfactory fire equipment tests were under taken on 19/9/05 and that fire drills and fire alarm testing have regularly taken place. As stated earlier above, the home has a smoking policy which service users are clear about. The pre-inspection questionnaire states that the gas boiler and the central heating system were serviced on 7/6/05. However, certificates were not available to confirm this on the day of the inspection. The inspector received a document titled the Landlord’s Gas Safety Record on 17/10/05, ten days after the inspection. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 19 An examination of this document showed that the home’s appliances and the heating system were serviced on 29/6/04, that is, approximately one year earlier than the date given in the pre-inspection questionnaire. The back door to the building was not safe in that it could be opened from outside even after locking it from inside. The registered person said the staff use a separate key at night to ensure that the door is appropriately locked. In its policy of quality review system, the home has committed itself to “carry out a six monthly service review”. There was no evidence, however, that the quality review has been undertaken recently. The registered person said service users and relevant stakeholders have been consulted regarding the quality of services and facilities but the document is held at the head office. A service user spoken to confirmed that they could talk to the staff and the manager. While the inspection was in progress a service user was observed interacting in a relaxed manner with the registered person. Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wimborne House Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000010779.V252062.R01.S.doc Version 5.0 Page 21 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 YA39 Regulation Requirement Timescale for action 31/12/05 2 YA42 24(1)(2)(3) The registered person must develop a system of quality assurance, which seeks the views of service users, representatives and professionals, and put in place an action plan, which helps address, any concerns which any party may have. The outcome of the quality assurance system must be made available to all stakeholders including the CSCI. 23(4) The registered person must 30/11/05 ensure that the gas boiler and the heating system are in working order. Appropriate certificates/records that confirm that the gas boiler and the central heating system have been checked and are in good working order must be sent to the CSCI inspector. 23(1)(2)(4) The registered person must ensure that the back door has an internal locking facility that meets the fire safety requirement. 15/11/05 3 YA42 Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 22 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 Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Wimborne House DS0000010779.V252062.R01.S.doc Version 5.0 Page 24 - 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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