Inspection on 15/12/05 for York Road (14a)

This inspection was carried out on 15th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Road (14a) 09/03/09

York Road (14a) 26/07/07

York Road (14a) 12/02/07

York Road (14a) 13/11/06

York Road (14a) 08/06/05

York Road (14a) 13/01/05

York Road (14a) 27/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 York Road (14a) 14a York Road Sutton Surrey SM2 6HG Lead Inspector Deborah Yapicioz Unannounced Inspection 15th December 2005 08:25 York Road (14a) DS0000007149.V270952.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 York Road (14a) DS0000007149.V270952.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. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service York Road (14a) Address 14a York Road Sutton Surrey SM2 6HG 020 8643 9612 020 8643 1662 h4062@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Mr Mohammad Iqbal Sohawon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: 14A York Road is a purpose built facility situated in a mainly residential street, between Sutton and Cheam. The home is close to local transport and facilities. Threshold Housing and Support owns the building although the residential unit is managed and staffed by Men Cap. The home provides care to six service users who have learning disabilities, autism and challenging behaviour. There are six single bedrooms, a lounge, dining room, kitchen and laundry. There are bathrooms and toilets situated through out the home. The home also has a large garden to the rear of the property. There is also ample parking to the front of the house. The home has its own transport in the form of a people carrier. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place on the morning of 15th December 2005 with a follow up visit on 19th December 2005 to check on staff records. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. A previous inspection took place on 8th June 2005 when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Methods of inspection included meeting with the service users, a partial tour of the premises, observation of contact between staff and service users, meeting with the manager, Iqbal Sohawon and other members of staff. Records examined included service user plans, risk assessments, medication records, complaints, staffing records, health and safety and fire records. The inspector would like to thank the service users, the staff team and Mr Sohawon for their help in facilitating the inspection. What the service does well: What has improved since the last inspection? What they could do better: One area of concern during the inspection was the fact that Criminal Records Checks for all staff were not in place. At the time of the first visit on 15th December 2005 a POVA check had not been received for two permanent York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 6 members of staff who were working without the necessary Criminal Records Checks. Following a discussion with the home manager agreed not to have the staff members concerned on the staffing rota until a clear POVA has been received. Another visit took place on the 19th December when a POVA check for both staff had been applied for. The home manager is reminded that no one should be employed at the home without the necessary POVA and Criminal Records Checks. The lighting throughout the home remains an issue particularly in the living room, kitchen and hallways. The home manager informed the inspector that Threshold (the housing association) have agreed to “make good” the lighting system which is not proving to be as efficient as had been hoped. Staff supervision sessions at the home are not taking place as often as they should, which is acknowledged by the home manager. The frequency that staff supervisions take place needs to be increased. 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. York Road (14a) DS0000007149.V270952.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 York Road (14a) DS0000007149.V270952.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): 1,2,5 The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. Each of the service users is issued with an individual contract setting out the terms and conditions of the placement, which safeguards the interests of both parties. EVIDENCE: The home has a statement of purpose and a service users guide. Both documents contain the information required by the Standards. Men cap has its own guidelines for service users selection and assessment prior to moving to the home. The home only accepts referrals following an assessment completed by a care manager. The care manager referrals were seen on service users files. The home also completes an assessment. Compatibility with others already living in the home is also taken into account. Any prospective service user would have a gradual introduction to the home with a series of short visits and overnight stays. The time frame would be flexible depending on the service user. Each of the service users has a personal contract on their file, specifying the terms and conditions of their occupancy that included periods of notice, fees charged, and the cost of ‘extras’ not covered by the basic cost of the placement. York Road (14a) DS0000007149.V270952.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): 6,9.10 The service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs and ensure service users wishes are represented. The home operates a risk management strategy thus enabling the service users to participate in activities in the home and in the community with appropriate support. EVIDENCE: Each of the service users has an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The home has a key worker system. The home manager explained that part of the key worker role is to advocate for the service user and involve them in the decision making process of the home. The key worker also reviews the Life plan every three months. The three monthly review leads into the service users annual review. Copies of the three monthly reviews and annual appraisals were seen on the service users files. The home operates a risk management strategy. Service users at the home have individual risk assessments depending on their needs and goals. Challenging behaviour guidelines were also seen on the service users files. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 10 Since the last inspection the home manager has purchased a lockable cabinet were the service users files are now kept. York Road (14a) DS0000007149.V270952.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): EVIDENCE: Standards 12,13,15,16,17, were all assessed as met at the previous inspection York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 12 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): 18,20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. EVIDENCE: The service users need varying degrees of assistance with their personal care. The level of support a service user needs would be detailed and recorded at their review. Personal care is provided in private, and timings of this are also flexible. The home provides consistency and continuity through designated key workers. Service users have access to relevant professional support to maximise independence, including the Community Team for People with Learning Disability. Significant events and accidents are recorded and monitored. Staff members monitor service user’s health and maintain up to date records. The home has a policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. All medication records were complete at the time of the inspection. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 13 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): 22,23 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives and ensure their concerns will be dealt with sensitively. The home has the appropriate policies in place to ensure the protection of vulnerable service users EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The home has a copy of the local authority Adult Protection Policy on site. The staff team have attended training on adult protection issues. The staff team are aware of the action they must take if they need to report an incident. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 14 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): 24,27, The home is a modern purpose house on a housing complex. The general décor of the home has recently been improved providing a homely, comfortable and safe environment for service users to live. The lighting in some of the homes communal area is not efficient and needs to be investigated to ensure a homely, bright environment for the service users. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: 14A York Road is a purpose built bungalow for service users with challenging behaviour and autism. It is situated next to another residential home in a quite residential area. The home is registered to cater for service users with learning disabilities and challenging behaviours and is suitable for its stated purpose. There is a lounge and dining room on the ground floor. The ground floor communal areas of the home have recently been redecorated and new furniture has also been ordered. One of the service users spoken to during the inspection said she liked the new colour scheme particularly the hallway. The kitchen has been repainted and the housing association is due to replace the kitchen cabinets. The home manager explained that the first floor of the home is due to be redecorated early in 2006. The lighting throughout the home remains an issue particularly in the living room, kitchen and hallways. The home manager informed the inspector that York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 15 Threshold (the housing association) have agreed to “make good” the lighting system which is not proving to be as efficient as had been hoped. York Road (14a) DS0000007149.V270952.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): 34,36 The appropriate Criminal Records Checks for all staff are not all in place and this may put residents at risk from employees who are unsuitable to work with vulnerable adults. Although the staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home, there is a need to ensure that they receive supervision on a regular basis to safeguard the quality of care. EVIDENCE: The inspector was concerned to note that Criminal Records Checks for all staff were not in place. In the absence of a Criminal Records Checks and in exceptional circumstances the Commission for Social Care Inspection will consider the employment of staff with a POVA check. However at the time of the first visit on 15th December 2005 a POVA check had not been received for two permanent members of staff who were working without the necessary Criminal Records Checks. Following a discussion with the home manager who agreed not to have the staff members concerned on the staffing rota until a clear POVA has been received. The inspector visited again on the 19th December when a POVA check for both staff had been applied for. The home manager is reminded that no one should be employed without a POVA and Criminal Records Check. Staff supervision sessions at the home are not taking place as often as they should, which is acknowledged by the home manager. The frequency of staff supervisions need to be increased. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 17 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): 42 In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised, however fire drills must be increased. EVIDENCE: York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 18 Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. The home has a health and safety policy in place. Environmental risk assessments are also in place. A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen. Health and safety law posters issued by the health and safety executive were on display. All staff must attend mandatory health and safety training including moving and handling. New staff members at the home complete health and safety training as part of their induction. Medication training by Boots is also part of the induction. The home needs to complete regular fire drills in keeping with the company’s policy. York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 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. 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 3 x x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 1 x 2 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 York Road (14a) Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000007149.V270952.R01.S.doc Version 5.0 Page 20 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 YA34 Regulation 17-(2) Sch4.6 Requirement The registered person must ensure that records of all persons employed at the home are kept in the home and include copies of everyones birth certificates, passport, and two written references obtained in respect of them. The home manager must ensure that regular fire drills are carried out. The home manager must replace the bulbs in the circular ceiling lights in the homes communal areas and investigate the reason why they have a short lifespan. The home manager must ensure that all staff receive regular recorded supervision. Timescale for action 15/12/05 2. 3. YA42 YA24 23(4(e 23(2(d 15/12/05 31/03/06 4. YA36 18(2) 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 21 York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 22 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 © 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 York Road (14a) DS0000007149.V270952.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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