Inspection on 15/08/05 for Wortley Lodge

This inspection was carried out on 15th August 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Wortley Lodge 27/11/07

Wortley Lodge 29/01/07

Wortley Lodge 25/01/06

Wortley Lodge 08/10/04

Wortley Lodge 28/06/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Wortley Lodge 26 Wortley Road East Ham London E6 1AY Lead Inspector Nurcan Culleton Unannounced Inspection 15TH August 2005 11.30am 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. Wortley Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Wortley Lodge Address 26 Wortley Road, East Ham, London, E6 1AY 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 8472 9974 020 8472 9974 Mrs Pretim Singh Mrs Pretim Singh Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Wortley Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8th October 2004 Brief Description of the Service: Wortley Road was registered in July 1995 as a 3 bedded home offering permanent accommodation for 3 adults with learning disabilities aged 18 to 65 years. The home comprises three single bedrooms, two bathrooms, large lounge, dining room fitted kitchen and has a paved garden. It is situated within the Upton Park area of East London, close to amenities and served by many bus routes to the area. The proprietor is also the manager of the establishment. The home excludes adults who exhibit severe challenging behaviour. Wortley Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 15th August 2005. The Registered Manager was not present in the home at the time of inspection and the inspector was assisted by the support worker on duty. All three service users were in the home during the inspection. The inspector spoke with two service users. One service user is non-verbal in communication. The inspector also spoke with two staff members, toured the premises and examined a range of documentation, including service users’ files. The current service users have been residing at the home on a long term basis therefore no new service users have been admitted for several years . What the service does well: What has improved since the last inspection? What they could do better: Nine requirements are given in all including three requirements which are restated following the last and previous inspections. These are that contracts must be signed by service users or their representatives; service users must have annual reviews and the adult protection training must be arranged for staff. New requirements have also be given in this inspection: all care plans must be signed by service users; the complaints policy must be amended to clarify service users’ rights; the home requires some repair or replacement of bedroom furniture and some decoration to ensure the premises are in good repair. Wortley Lodge Version 1.10 Page 6 New and improved window restrictors are required to ensure the health and safety of service users and some health and safety certificates are required. The Registered Manager must ensure that all requirements are completed within the given timescales of this report. The Registered Manager must be aware that continued lack of meeting requirements could lead to enforcement action being taken. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wortley Lodge Version 1.10 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 Wortley Lodge Version 1.10 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, 3, 5 Service users are provided with information prior to and during their admission to the home. Service users’ assessed needs are met in the home. Service users’ contracts must be signed by service users. EVIDENCE: The Statement of Purpose and Service Users’ Guide were viewed and contained all the elements as required by regulation. The service users’ complaints policy however as also contained in the Service Users’ Guide must be amended to state that service users have a right to complaint to the CSCI directly. Records seen and staff and service users spoken to provided evidence that the home had the capacity to meet assessed needs. Two out of three contracts seen in service users’ files were not signed. Service users’ signatures in contracts were required at the last inspection in October 2004. This requirement is restated in this inspection report. This requirement must be complied with by the timescale specified in this report. Wortley Lodge Version 1.10 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 standard(s) 6, 7, 8, 9, 10 Service users’ needs are identified and reflected in their service user plans. Service users are enabled to express their views and make decisions about their lives and to take responsible risks. EVIDENCE: The inspector viewed three service user plans which were comprehensive in outlining service users’ needs. In addition, plans are supported by professional intervention where necessary, such as through a speech and language therapy and psychology reports. Minutes of a staff meeting stated that all care plans were signed, however one plan seen in one service users’ file was not signed by either the service user or their representative. Signatures in care plans by the service user or their representative is a requirement by regulation. One service user has an advocate and the other two service users are represented by their parents who are actively involved in their care. Service users’ views are recorded in monthly service users’ meetings. Views expressed in the minutes book included social activities, the menu, housework, the menu and college courses. Service users are enabled to take responsible risks and risk assessments were seen as part of service user plans. Minutes of review meetings seen in two service user files were overdue. Service user reviews must take place and this requirement is restated following the last two inspections. Wortley Lodge Version 1.10 Page 10 Wortley Lodge Version 1.10 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Service users are offered opportunities for personal and social development through participation in a range of meaningful social and personal activities. Service users’ rights are respected and their daily routines promote independence and choice, subject to the needs identified in service users’ plans. EVIDENCE: The programme activities chart in the dining room was viewed by the inspector as well as individual activity programmes in files. Two service users attend college in Newham to do Yoga, relaxation, music, art, reading and numeracy. One service user attends the NuLife day centre on a daily basis. All three service users also engage in a range of social activities programme. These include attendance at Mencap social group, the cinema, library, local pubs, tea dances, cinemas and other local facilities such as shops and restaurants. One service user goes to the local shop independently and is known by the shopkeeper. Service users are supported to vote and staff support them to attend polling stations in doing this. One service user is able to prepare her own meals with support. Another is able to make tea for herself and others. Service users engage in domestic chores like cleaning. Wortley Lodge Version 1.10 Page 12 One service user has her own key. Assessments are in place for the two service users who do not have keys. The menu seen was varied and nutritious. Service users choose their meals and informed that they liked their meals. Wortley Lodge Version 1.10 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 standard(s) 18, 19, 20, 21 Service users are offered individual, personalised support tailored to meet their needs. Service users’ physical, mental and emotional needs are addressed and met in the home. Medication is appropriately administered and controlled. EVIDENCE: Documents seen by the inspector and interviews held showed that the needs of service users in the home were variable, as outlined in their individual care plans. Support workers offer full personal care support for one service user to varying levels of direct support, prompting and supervision with the other two service users. Service users have good access to healthcare services, including their own GP and and the Community Team where service users can access other facilities for their health care including mental health care needs. Medication records were checked against medication administered and were deemed to be correct at the time of inspection. A previous requirement concerning the disposal of medicines was met. The inspector viewed a form developed for this purpose and a signature was seen to witness the disposed medicines. Each service user has a signed statement concerning their death and dying personal wishes. Wortley Lodge Version 1.10 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 standard(s) 22, 23 Service users views are listened to and acted on. Adult protection training must be arranged for all staff to promote the safety of service users. EVIDENCE: There were no complaints logged in the complaints book. The lack of complaints and satisfaction felt by service users in the home was supported by documents examined by the inspector. The inspector examined service users’ views expressed in the minutes of the monthly residents’ meetings and the yearly quality assurance questionnaires. Positive views were noted. Statements included “staff are supportive”, “I am happy in the home”, “I like the way things are”. The complaints policy must however be amended to state that service users have the right to refer their complaint to the CSCI at any stage. Minutes of the last team meeting seen by the inspector evidenced a discussion about adult protection training. The Registered Manager informed the team that the trainer arranged to provide adult protection training had cancelled the training and alternative training had to be arranged. This is a priority and the requirement is restated following the last inspection. The inspector was unable to ascertain from the support worker whether the home had obtained a copy of the Local Borough’s adult protection procedure. Wortley Lodge Version 1.10 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 standard(s) 24, \25, 26, 27, 28, 29, 30 Service users environment is homely, comfortable and suitable for their needs. Some health and safety issues are raised and need for decoration to meet its stated purpose. EVIDENCE: The inspector viewed the home with the assistance of a service user. Bedrooms viewed are sufficient to meet service users’ needs. Rooms were clean, tidy and personalised with pictures on walls, photographs, personal effects, including a fish tank in one service users’ room. However the chest of drawers in two service users’ rooms were broken and need repair or replacement as soon as possible. The issue of the broken chest of drawers was raised in a residents meeting in April, therefore this needs to be addressed as soon as possible. The inspector noted that service users’ bedroom walls and the lounge wall needs repainting. The inspector considered the window restrictors to be inadequate as regards health and safety as they open very widely. In one case, the window restrictor was broken entirely, posing a major health and safety risk as there is direct access to the roof through the window. Window restrictors must be adequate and repaired as soon as possible. The home was generally clean, tidy and homely. Wortley Lodge Version 1.10 Page 16 Wortley Lodge Version 1.10 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 Service users benefit from staff who are clear about their roles and responsibilities and have a clear understanding of service users’ needs. There are sufficient staff numbers and staff are well supported to fulfil their support tasks. EVIDENCE: Staff interviewed gave a clear understanding of the needs of the service users. The staff team and service users in the home have been stable for a long period enabling staff to develop their knowledge and skills in working with the service users. Service users spoken to had limited communication skills, however indicated that staff respect them and respond to their needs. This was evident also in minutes of the residents’ meeting. The support worker interviewed informed that she and all other staff had completed NVQ Level 2s and that she would soon begin an NVQ Level 3. The provision of adult protection training requirement is restated as the training had been cancelled by the trainer according to staff team minutes. There are currently three staff members employed and one staff member is on sleep-in duty at night. Supervision is given on a two monthly basis. The support workers informed they received adequate support from the Registered Manager and there was a good team spirit. Staff files could not be assessed as the support worker did not have access to this information. Wortley Lodge Version 1.10 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 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) 38, 39, 41, 42 The management approach of the home is open, positive and inclusive. There are strategies in place to enable staff and service users to express their views and service users benefit from a well run home. EVIDENCE: Service users’ view of the management approach of the home is positive as minutes of meetings seen indicate their satisfaction with the staff, of how they are treated and in living in the home. This was also reaffirmed in annual quality assurance questionnaires completed by staff and service users. Staff spoken to informed that the Registered Manager was approachable and supportive. Records seen were generally in good order and systems are in place for the efficient running of a care home. Aspects of health and safety were examined. The home observes good health and safety practises. Water temperatures and fridge/ freeze temperatures are taken daily. Fire drills take place every 3 months. Certificates of gas, electricity and water safety were not available in the health and safety file presented to the inspector. These must be current and available for inspection. Reference has been made concerning the need for improved window restrictors needed in bedrooms. Wortley Lodge Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 N/A 3 N/A 1 Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 1 3 3 3 3 Standard No 11 12 13 3 3 3 Standard No 31 32 33 34 35 Score 3 3 3 N/A 3 Page 20 Wortley Lodge Version 1.10 14 15 16 17 3 3 3 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score N/A 3 3 N/A 3 1 N/A Wortley Lodge Version 1.10 Page 21 yes 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 5 Regulation 12, 16 Requirement The Registered Manager must ensure that service users’ contracts are signed by the service user or their representative. The Registered Manager must ensure that all care plans are signed by service users. The Registered Manager must ensure that each service user receives an annual statutory review. The Registered Manager must ensure that the complaints policy includes that service users have the right to refer their complaint to the CSCI at any stage should the complainant wish to do so. The Service Users Guide must also be updated to reflect this. The Registered Manager must ensure that all staff receive training on Adult Protection Issues. The broken chest of drawers in two service users’ rooms need repair or replacement as soon as possible. The Registered Manager must ensure that service users Version 1.10 Timescale for action 25th October 05 2. 3. 6 6 15 14 (2), 15 25th October 05 25th November 05 25th October 05 4. 22 22 5. 23 13 (6) 25th November 05 25th September 05 25th November Page 22 6. 24 23 7. 24 23 Wortley Lodge 8. 42 13 (4) 9. 42 13, 23 bedroom walls and the lounge wall are redecorated. The Registered Manager must ensure that window restrictors are in place and are adequate for their purpose. The Registered Manager must ensure that certificates of safety must be available for gas, water, electric wiring and Portable Appliance testing (PAT). 05 25th September 05 25th November 05 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 Good Practice Recommendations Wortley Lodge Version 1.10 Page 23 Commission for Social Care Inspection Gredley House 1-11 Broadway London E15 4BQ 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 Wortley Lodge Version 1.10 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. 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