Inspection on 22/02/06 for York Road (31)

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

York Road (31) 19/06/08

York Road (31) 26/07/07

York Road (31) 13/12/06

York Road (31) 09/12/05

York Road (31) 14/02/05

York Road (31) 04/11/04

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 York Road (31) 31 York Road Sutton Surrey SM2 6HL Lead Inspector David Pennells Unannounced Inspection 22nd February 2006 11:20a York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 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 (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service York Road (31) Address 31 York Road Sutton Surrey SM2 6HL 020 8642 6310 020 8642 9807 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) www.together-uk.org Together Working for Wellbeing Mr Martin Wolckenhaar Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th December 2005 Brief Description of the Service: 31, York Road is an extensive Edwardian building, providing accommodation both in this substantial ex-family house and in an additional, more modern, annexe - located in the home’s back garden. The house is situated on a pleasant residential street with a ‘hail & ride’ bus service - and is located in the Belmont area (BR station), south west of Sutton - and slightly closer to Cheam Village, both these more principal towns having rail links also. There is limited parking on site, and extensive [free] parking on the broad street outside. The house provides a service to fourteen people aged 18 - 65 with severe or complex mental health needs. The house provides support to people who require a period of supported rehabilitation after discharge from hospital, prison, and alcohol / drug detoxification units. The main house provides a large (smoking) lounge, a (non-smoking) dining / living room and a substantial kitchen with good, modern catering facilities. A second small lounge is available in the ‘loft’ level of the house - this is used for meetings, reviews - and as a ‘bolthole’ for those seeking peace and quiet. All bedrooms are single occupancy and are well appointed. The rear garden provides a secluded retreat in good weather. The Annexe provides one activity area - where a computer is located, as well as bedrooms and the staff sleeping-in room. An administrative / staff office is provided in the other main room on the ground floor - close to the front entrance of the house. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit found the house, as ever, in a state of active engagement, with all living life to the full. The registered manager was present at the house and was able to assist the inspector to review the requirements and recommendation from the previous report - whilst also engaging with service users and staff. The inspector was also able to speak to the majority of service users at the home, and also stayed for the morning-to-afternoon staff members’ handover meeting. The inspector thanks all at York Road for their welcome, co-operation and for the hospitality shown - throughout the inspection visit. What the service does well: What has improved since the last inspection? Medication records are now being kept consistently with rigorous attention being given to correct recording processes. Risk assessments as well have been stepped up to ensure the safety of service users at the home. An identified risk of scalding from a radiator in the small upper floor bathroom has been resolved through the insertion of a radiator cover. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 6 The visit reports of the representative of the persons in control - the ‘linemanager’ - are now copied on to the Commission. Another noteworthy improvement, among other things, is that the manager’s health has improved; his absence for medical intervention soon after the last inspection visit has hopefully put him back on the road to the rudest of good health - this will certainly encourage the service from strength to strength. What they could do better: 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 (31) DS0000036098.V283037.R01.S.doc Version 5.1 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 (31) DS0000036098.V283037.R01.S.doc Version 5.1 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): none inspected fully at this visit. Service users can expect that adequate information will be provided both prior to and during the assessment phase of an application to live at York Road. Assessment will include seeking an understanding of individual aspirations and needs and these are assessed against the home’s ability to meet them. The home provides opportunities to visit and stay at the home, ensuring that compatibility in every respect is checked out. Service users are provided with contracts / licences of occupancy - importantly making explicit the terms and conditions of their stay at the home. EVIDENCE: All standards were inspected at the last inspection - and found ‘met’. Nothing at this visit indicated an expectation that the situation in these regards had changed since the last visit, and so the judgement statement paragraph from the last report is reiterated above for the assistance / information of readers of this report. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 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): none inspected fully at this visit. Service users can be assured that their individual aspirations and needs will be fully recognised and recorded within a personal plan – which will be amended over time to recognise changes as appropriate. Service users can expect to be encouraged and enabled to make decisions for themselves; staff providing an unobtrusive support system to assist service users in their best interests. Service users will be consulted on both personal and communal aspects of life at the home; this through involvement fully in their own programme and in communal decision making processes. Service users can expect that the focus on independent actions and decision making will be assisted by staff providing a risk-taking perspective, thus supporting service users to make informed choices and judgements. EVIDENCE: All key standards and standard 8 were assessed at the last visit and found ‘met’. The judgement statements are reiterated above for information. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 10 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): none inspected fully at this visit. Service users can expect York Road to provide opportunities for selfdevelopment through engagement in both external and internal activities suited to individual needs and aspirations. Service users are free to engage in local community activities and access leisure facilities. Families, friends and partners can expect to be welcomed and integrated as part of a service user’s lifestyle, with service users rights to privacy and dignity respected. The home provides a nutritious diet designed to satisfy and encourage healthy eating and to provide a positive eating experience. EVIDENCE: All standards above were inspected at the last inspection - and found ‘met’. Nothing at this visit indicated any significant change to the situation since the last visit - and so the judgement statements from the last report are reiterated above for the assistance / information of readers of this report. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 11 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): 20. Service user can rely on the home to assist them to keep well, through accessing appropriate healthcare and associated mental health care support. Service users can rely on the home providing a well-managed service relating to medication where service users are assessed as being unable to handle such issues themselves. Service users can rely on being cared for and supported throughout times of trauma as well as good health, with information about support needs provided. EVIDENCE: Review of medication issues has left the home with just one task - to tighten up system of formal criterion for any service user receiving medication that is prescribed on a ‘prn’ (‘when required’) basis. The inspector spent some time with the staff member responsible for the organisation of the medication systems - to ensure that they were clear about the necessary information / records required. It is hoped that this deficit will be properly addressed now that the issue has been fully ‘aired’. The remaining elements of the medication administration system are well ordered and maintained. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 12 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): 23. Complaints, compliments and suggestions will be positively handled by the home, resulting in an enhanced service for all - service users and staff alike. Adult protection issues will be appropriately recognised and handled at the home, however, as local and organisational guidance is currently [to an extent] conflicting, the provider must ensure a single version policy by blending theirs with the local authority to avoid any potential future conflict. EVIDENCE: The home has a clear complaints and suggestions procedure, which features prominently in the service User Guide, etc. - the organisation approaches such issues systematically -seeking to value such contributions and to view the opportunities they raise in a positive light. The home has previously evidenced that they take the protection of service users seriously, and are keen to protect their wellbeing. The home has a copy of the local authority’s revised Vulnerable Adult policy and procedure - ‘Together’ has its own policy, also. The previously-made recommendation that the registered provider should revisit / revise their policy on Vulnerable Adults - to commit to adhering to the local authority processes more closely (and to include reference to the POVA legislation), became a requirement at the last inspection visit – this due to the inspector’s concerns that staff may well find themselves relating differently to an abuse issue, dependent on whether they rely on the local authority’s procedure (which has the ascendancy in such matters) or the employer’s in-house document. The manager has committed to ensuring that the issue will be addressed. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 13 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 & 29. Service users can expect to live in a clean, warm and comfortable environment designed to meet their individual needs and providing adequate services and domestic facilities. Service users can be assured that, once the minor repairs and issues relating to radiator surface risks are addressed, the home will be a safe environment in which to live, without unnecessary risk. EVIDENCE: 31, York Road provides accommodation both in the substantial main house and an additional more modern ‘annexe’ located in the garden. The house provides a large lounge (smoking area), the majority of the bedrooms, a dining / living room (non-smoking) and a substantial kitchen with good catering facilities. A small lounge is also available in the ‘loft’ level - this is used for meetings, reviews, etc. The Annexe has a lounge / computer room and five bedrooms. There are adequate toilets available throughout both the house and the annexe; there are six bathrooms and five shower facilities available. The bath in the bathroom at the top of the house is now at the end of its life – chipped, York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 14 flaking and enamel-less - this is now due to be replaced; the lack of enamel can lead to cross-infection issues in communal areas such as this. The top floor shower room also requires attention: it has an inappropriate exposed fluorescent light fitting which must be changed to a more appropriate type of sealed lighting unit. The home is kept cleaned - and tidy - by a ‘task force’ of service users and staff who complete an excellent job in keeping the house looking clean and being odour-free. The service user group should again be proud of their ongoing achievement; the inspector hopes they will continue to take a pride in this excellent accommodation. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 15 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): 35. Service users can be assured that they will be supported at all times by staff who are experienced and competent in their work, being provided in sufficient numbers to meet their identified needs. Service users can expect to be provided a service that generally ensures their safety and protection from abuse and danger through a thorough recruitment process and staff training – though staff training in First Aid would equip staff members to address any emergency issues more competently. EVIDENCE: Staff training in First Aid is the required deficit in this set of standards; a regulatory and health & safety necessity. This area must be made a priority to ensure that every shift, 24/7, is covered by a First Aid qualified worker. The remaining standards in this section were inspected at the last visit and found ‘met’; the reiterated statements above reflect this achievement. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 16 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): 41. The registered manager and the home work within and operate management systems that ensure that service users benefit from a well-run, competently managed, open and safe environment. Service users can be assured that generally their rights and interests are well served and protected through the home’s approach to record keeping, policies & procedures, and the day-to-day conduct of the home. Service users can be assured that their welfare, health and safety is safeguarded through the home’s adherence to appropriate guidance and regulations concerning best safety practice. EVIDENCE: The registered manager will hopefully gain a start date to recommence his NVQ for the Registered Manager’s Award [at Level 4]; he is previously a qualified Registered Nurse - who still maintains his professional registration and is clearly competent in the management role at the home. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 17 The manager’s recent serious illness and a second subsequent hospitalisation has meant that he was forced to drop out of the previous course for the NVQ Level 4 RMA, however he is confident that he will attain the qualification - as required by this Standard - now that he is restored to health. The inspector hopes that the Registered Provider will provide appropriate incentive and encouragement that he qualifies as soon as is practicable. The Area Manager and other representatives of the organisation regularly visit the home and comment on the service. Regulation 26 reports compiled by the Registered Provider concerning the home are now copied regularly to the Commission - as required under this Regulation. Excepting the issues identified in the ‘premises’ sections and the First Aid training deficit, the home was found to be reasonably safe, and well covered with regard to health & safety issues in general. York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 18 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 2 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X X X X X 3 X X York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation 13(2) & 17 Requirement The registered provider must establish a much clearer set of Criteria for each and every PRN (‘when required’) medication used at the home. Timescale of 31/01/06 not met. The registered provider should revisit / revise the MACA policy on Vulnerable Adults - to commit to adhering to the local authority processes more closely. Timescale of 31/01/06 not met. The fire door at the top of the stairs entering the first floor corridor area must be adjusted to ensure it closes fully onto the door stops / smoke seals. Timescale of 31/12/05 not met. The bath in the bathroom at the top of the house must be replaced; the lack of enamel can lead to cross-infection issues in communal areas such as this. Timescale for action 31/03/06 2. YA23 13(6) 31/05/06 3. YA24 13(4) & 23(4) 30/04/06 4. YA27 23(2)(j) 30/04/06 York Road (31) DS0000036098.V283037.R01.S.doc Version 5.1 Page 20 5. YA27 23(2) (c) (p) The top floor shower room with an exposed fluorescent light fitting must have a more appropriate type of lighting unit provided. Timescale of 31/01/06 not met. 30/04/06 6. YA35 13(4) Staff training in First Aid must be 31/05/06 made a priority to ensure that every shift, 24/7, is covered by a qualified worker. 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 YA37 Good Practice Recommendations The registered manager should achieve his NVQ Registered Managers Award at Level 4 as soon as is practicable. 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