Inspection on 14/12/05 for 20, Glamorgan Road

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

20, Glamorgan Road 08/08/06

20, Glamorgan Road 17/08/05

20, Glamorgan Road 03/02/05

20, Glamorgan Road 17/08/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Glamorgan Road, 20 20 Glamorgan Road Hampton Wick Middlesex KT1 4HP Lead Inspector Sandy Patrick Unannounced Inspection 14th December 2005 09:30 Glamorgan Road, 20 DS0000017365.V261183.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 Glamorgan Road, 20 DS0000017365.V261183.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. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glamorgan Road, 20 Address 20 Glamorgan Road Hampton Wick Middlesex KT1 4HP 020 8296 8187 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) H4069@mencap.org.uk H4037@mencap.org.uk Royal Mencap Society Mr Myles Stevens Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (10) of places Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: 20 Glamorgan Road is a large house converted out of two buildings. The home is managed by Mencap and is registered for ten people with a learning disability. The building is owned by Richmond Churches Housing Trust. The home was set up to offer accommodation for service users leaving Normansfield Hospital, many of the original service users remain at the house. The philosophy of care is to offer ongoing support for service users to live within the local community and to develop and maintain skills of community living. The home is situated in a quiet residential street in Hampton Wick, and is close to local amenities. Staff support is offered twenty-four hours a day, and service users access a range of local services with support. Each service user is assigned a keyworker who provides individual support. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 14th December 2005, and was unannounced. The Inspector met with the Manager, other staff on duty and service users. The atmosphere at the home was quiet and relaxed. Service users were pursuing a number of different activities, some supported by staff. Many service users went out for the day to a variety of different places. Staff were kind and treated service users with respect. Service users were supported to make their own choices, about food, clothes that they wore and activities. What the service does well: What has improved since the last inspection? 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. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 6 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 Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 7 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): 3&4 Service users at the home have a wide range of needs. Staff work closely with other professionals to make sure these needs are met. People who are interested in moving to the service are able to visit and meet current service users and staff. EVIDENCE: The home offers a service to people with a diverse range of needs. The ages of service users at the house range from people in their 40’s to people in their 80’s. Some service users have sensory impairment, some have mental health needs and some have high mobility needs. Staff are appropriately trained and able to meet these needs. The home works closely with the Community Team for Learning Disabilities and other health care professionals to ensure that needs are met The needs of service users at Glamorgan Road have changed over the years and now some of the service users are reaching older age. Their health, mobility, emotional, dietary and physical needs are all changing. The Manager reported that training and support from local health care professionals and other agencies was provided so that staff were aware of how to meet some of these changing needs. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 8 Additional funding is provided for some service users to have individual support to meet some of their needs. This is regularly reviewed by multidisciplinary teams. There was one service user vacancy at the home at the time of the inspection. The Manager reported that a potential service user had visited the home and was due to visit again. If they are interested, further visits, including mealtimes and overnight stays will be arranged. Glamorgan Road, 20 DS0000017365.V261183.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 & 9 Service users’ needs are represented within individual service user plans. Work to promote a person centred approach is taking place. Service users are able to make choices about their lives and the running of the home. Service users are supported to make informed choices and take risks where appropriate. EVIDENCE: Service user plans are in place for all service users. Some of these need reviewing and updating in line with changes in need. Staff are working with service users to develop a person centred approach. The staff are at different stages of this with different service users. Some service users have developed creative photographic accounts to support written care planning information. Others had used the computer, videos and other equipment to help express their needs. The work undertaken by service users and staff has been positive. Further work to create a more person centred approach continues. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 10 Throughout the inspection, staff were observed to use different communication techniques, including Makaton, to support service users to understand them and to be understood. Staff receive training in this area. Information throughout the house is presented in pictorial form and with the use of photos. Service users are supported to understand Makaton signs and symbols and staff work with service users to identify the signs and symbols that are meaningful to them. Service users are supported to make informed choices and take risks. Assessments of risk have been developed for all service users, in consultation with them and other relevant parties. These are regularly reviewed. The Inspector examined assessments of risk for three service users. There was evidence that staff were aware of the support they needed to give in each case. Glamorgan Road, 20 DS0000017365.V261183.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): 11, 12 & 13 Service users are supported to develop and maintain skills. Service users are valued members of the local community and participate in a range of activities both inside and outside of the home. Service users are supported to participate in households tasks, menu planning, shopping and meal preparation. EVIDENCE: There are regular service user meetings and service users told the Inspector that they participated in these. Service users are involved in shopping, household tasks and cooking at the home. Some of the service users spoke about this, telling the Inspector how they planned menus, shopped for food and held prepare meals. One service user told the Inspector that they went out alone and used public transport as they needed. People living at the home have varying degrees of support to use transport, shops and money and all service users have active lives, which involve accessing local resources and facilities. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 12 Service users at the home have a variety of planned activities, including work, college courses and attending local resource centres. Their individual needs are reviewed on a regular basis and planned activities are designed to meet these individual needs. Service users told the Inspector that they were consulted about what they wanted to do. On the morning of the inspection, service users and staff were busy preparing for their day ahead. One service user was making their own packed lunch, whilst staff offered advice and support as needed. Other service users were having breakfast, getting ready to go out and helping to clear away the breakfast things. Staff were heard to offer service users choices. Service users were encouraged to do as much for themselves as they could. One service user told the Inspector that they were going Christmas shopping, other service users were going to work or resource centres. One service user was going to the cinema with their support worker. Glamorgan Road, 20 DS0000017365.V261183.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): 18, 19 & 20 Personal and health care needs are appropriately recorded and monitored. Some improves to medication practices are required. Staff who do not follow medication procedures are putting service users at risk. EVIDENCE: Personal and health care needs are recorded within service user plans. There is evidence that these are monitored by staff. Each service user plan contains a compatibility chart, which includes details on emotional needs, preferences for age and gender and cultural needs regarding personal care. The themes of upholding privacy, dignity and choice are present throughout all information. Information is subject to regular review. All service users are registered with local GPs. The Community Team for Learning Disabilities and other health care professionals offer support and training to staff and work directly with some of the service users. There is an appropriate procedure regarding medication. All staff are trained in the administration of medication. A dosage of medication had been decanted from its original container and left in an unmarked pot in the medication cabinet. This was administered to a Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 14 service user during the inspection. The practice of decanting medication into new containers and left before it is administered is not necessary and presents a risk. Medication must never be left in unlabelled containers. Some of the homely remedies and vitamin tablets belonging to service users and stored in the main medication cabinet had not been labelled and must be. Medication administration records were accurate and regularly completed by staff. The amount of recently prescribed medication held at the home was recorded. However, the amount of medication which had been dispensed some time ago (such as pain killers) and held at the house for several months had not been recorded. The total amount of all medication held at the home must be recorded and records updated as required. There is no record to show the staff signatures and initials. This record should be developed. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 There is an appropriate procedure for reporting and investigating complaints. There is a record of all complaints and informal concerns. EVIDENCE: There is an appropriate complaints procedure, detailing timescales and information on contacting the Commission for Social Care Inspection. There have been no formal complaints since the last inspection. record of informal concerns and the action taken to remedy these. There is a Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30 The home is comfortable and suitable for its purpose. building are in need of refurbishment or redecoration. Some areas of the Service users have unrestricted access to communal areas and bedrooms have been personalised. The home was clean and well ventilated throughout. EVIDENCE: The home is situated in a quiet residential road in Hampton Wick. Accommodation is provided on three floors in a converted building. There is ample communal and private space and service users have personalised their rooms and the communal areas. The upkeep and maintenance of the building has been problematic in the past and some necessary work has remained outstanding for long periods of time. The home is starting to look worn in some places. The home was decorated for Christmas and one service user told the Inspector that they had helped with these decorations. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 17 The Manager reported that funding to replace kitchen units and surfaces had just been approved and it was hoped that this work would start early in 2006. A new dishwasher had recently been purchased. The lounge and other communal areas would benefit from redecoration as walls and woodwork are marked and looking worn. For some time, work to replace rotten windows, paint internal and external woodwork and to redecorate two WCs has been needed. The condition of these areas of the building has worsened with time and the Registered Person must make sure that the decorative needs of the home are met. The requirement made at previous inspections is restated. There is evidence in service user plans of consultation with and assessment by Occupational Therapists and Physiotherapists about individual equipment and adaptation needs. The home was clean and well ventilated throughout. Service users participate in some cleaning and laundry tasks. A part time cleaner is employed and support staff undertake some of the cleaning duties. There are appropriate procedures regarding disposal of clinical waste, infection control and Control of Substances Hazardous to Health. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 18 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): 31, 34, 35 & 36 Staff at the home are given information, training and support so that they can meet the needs of service users. The recruitment procedure is designed to make sure staff employed are suitable. EVIDENCE: Since the last inspection a new system of shift planning has been introduced. The Manager said that this was working well and all staff were confident in allocating and being allocated different tasks. There is a file of information for new and temporary staff about the procedures and practices at Glamorgan Road and giving basic information on service users. This has recently been updated and provides a guide for all staff as required. There are appropriate procedures for the recruitment and selection of staff including a panel interview chaired by the Manager. One member of staff has been employed since the last inspection. Their recruitment records were examined. These were complete and there was evidence of thorough preemployment checks. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 19 Regular team meetings are organised and there are appropriate records of these. These indicate that staff discuss various practices and are giving information and training as appropriate. A staff meeting had been organised for the day of the inspection. The staff on duty told the Inspector that these meetings were a useful support. Staff on duty told the Inspector that they had regular supervision. Records of monthly supervisions, signed by the staff were seen. There is a comprehensive programme of training offered to staff. Individual training records indicated that staff had undertaken a range of training. There is an appropriate induction and foundation package of training for all staff. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 20 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): 38, 39, 40 & 42 There are systems in place so that the quality of the service, the safety of the environment and the management of staff are checked on a regular basis. EVIDENCE: The management structure in the organisation changed shortly before the inspection and the home had a new line manager who was visiting on the day of the inspection. The Registered Manager said that the new management structure had not been tested yet and was unable to comment on whether this would improve support for him and the home. The Area Manager visits the home to conduct unannounced quality inspections once a month. Reports of these visits are made and should be forwarded to the Commission for Social Care Inspection. These visits have taken place, but copies of the reports are not always being sent to the Commission for Social Care Inspection. The Registered Person must make sure that copies of these reports are sent to the CSCI. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 21 Not all records and policies and procedures at the home had been dated. The Manager should make sure that all records are dated, and that any review dates are also recorded. Regular and thorough checks are made on health and safety at the home. These are appropriately recorded. Checks on general health and safety, fire safety, the house vehicle, first aid supplies, water and food storage temperatures were seen. There was evidence that any health and safety needs were followed up. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 22 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 X 3 3 X Standard No 22 23 Score 3 X 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 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glamorgan Road, 20 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X 3 2 3 X 3 X DS0000017365.V261183.R01.S.doc Version 5.0 Page 23 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 YA20 Regulation 13(2) Requirement The Registered make sure: Person Timescale for action must 15/01/06 is 1. All medication appropriately labelled. 2. Medication is not taken from its original container prior to administration. 3. A record showing all staff signatures and initials is developed. 4. A record of the amounts of all medication held at the home is maintained. 2. YA24 23(2)(b) The Registered Person make sure must 31/03/06 that: 1. The repair and decorative needs are addressed. 2. There is a regular programme of maintenance so that repair and decorative needs to not remain outstanding for Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 24 unacceptable periods of time. Previous requirement 30/06/05 and 31/12/05 3. YA39 26(5)(a) The Registered Person must 31/01/06 make sure that reports of monthly visits to the service by the line manager are forwarded to the Commission for Social Care Inspection. Previous requirement timescale 30/09/05 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 YA40 Good Practice Recommendations The Registered Person should make sure all records are appropriately dated and reviews on records are recorded. Glamorgan Road, 20 DS0000017365.V261183.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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