Inspection on 08/08/06 for 20, Glamorgan Road

This inspection was carried out on 8th August 2006.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

20, Glamorgan Road 14/12/05

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 20, Glamorgan Road Hampton Wick Middlesex KT1 4HP Lead Inspector Louise Phillips Unannounced Inspection 8th August 2006 09:30a 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 20, Glamorgan Road Address Hampton Wick Middlesex KT1 4HP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8296 8187 H4069@mencap.org.uk www.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 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 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 residents leaving Normansfield Hospital, many of the original residents remain at the house. The philosophy of care is to offer ongoing support for residents 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 residents access a range of local services with support. On the day of inspection the manager stated that the fees charged by the service are £749.31 per week. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a one day site visit and a period of time seeking feedback from professionals associated with the service. A tour of the premises was carried out and care records were inspected along with other relevant paperwork. Time was spent talking to three staff and two residents. Information has also been gained from the inspection record for the home. Questionnaires were sent to eleven health and social care professionals and three of these were responded to. 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. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made as there is a good assessment process for new residents moving to the service to ensure that the home can meet their needs. Staff are also trained to meet the changing needs of residents at the service. EVIDENCE: Since the last inspection one new resident has moved to the home. Their care file contains information about the referral and assessment prior to their moving to the home, with details about their personal care, important relationships, etc. In addition there is information about any areas of risks that need to be planned for. New admissions to the service are planned, which take place through day visits and overnight stays. A care plan is developed for their settling into the home over a three week period, including details of what they like to do and typical routines throughout the day. Records indicate that after about two weeks living at the home there is a review to see how they have settled in, followed up by another review with the care manager after the first four months, where the resident decides if they wish to stay at the home, and any issues regarding their move are finalised. The manager spoke about how the needs of the existing residents at Glamorgan Road are continually assessed, particularly where they are becoming older and requiring more support from staff. He spoke 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 8 enthusiastically about having recently received additional funding to enable there to be more staff on duty, particularly in the mornings where residents need extra support with personal care. Staff have also been trained in bereavement, change and loss to enable them to better meet the ageing and changing needs of residents. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made as resident’s needs are met by the service, and they are involved in their care planning. EVIDENCE: Health and social care professionals involved with 20 Glamorgan Road are positive about the service meeting the needs of the residents. They also feel that the home operates in the best interests of the person and that specific cultural, ethnic and disability issues are addressed, one comment being that: “…the home have responded to clients changing needs of mobility…”. The care plan files for two residents were looked at. Records indicate that these are reviewed approximately every eight weeks with the involvement of the resident. The care plan includes a personal profile of the resident, their history, what they like to do and important relationships in their life. There is information about their level of functioning with regard to such things as telling the time and level of comprehension. In addition there is information about any personal care needs of the residents and the staff support needed for this. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 10 The health, emotional and behavioural support needs of residents are well documented, along with the treatment and care needed to assist residents with this. The manager stated that person-centred plans (PCP) are being introduced for each resident at the home, and that these are at varying stages of development. The PCP for one resident had been done on a computer and provided photographic information and a written summary of what they like to do, relevant people in their life, what they like to eat and do throughout the week. they like to eat, where they like to eat, what like to do each day of the week. Each service user has a comprehensive risk assessment for areas such as bathing, travelling outside the home, self-medicating, etc. These were implemented at dates between 2003 and 2005, though monitoring records demonstrated that these are reviewed annually, along with additional risk assessments in place to reflect changing needs. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made as the residents have are involved in activities that are planned around their needs, interests and community living. Residents are fully involved in menu planning and meal preparation. EVIDENCE: Healthcare and social care professionals were asked where they feel the home provides excellent service. Two responded to this with the following comments: “…the staff are in tune with valuing people and are working with us to seek to provide the sort of lifestyle their residents want…”, “…client’s day time activities have been reviewed and expanded…”. Each resident has weekly plan based on their individual preferences, such as going to the day centre, going to work, going to church, college course or doing a home-base day where they are supported with doping their laundry and cleaning their room, etc. On the day of inspection one resident was supported to attend a singing group, one was at work, another on a home-base day and some were collected by transport to go to the daycentre. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 12 Residents on a home-base day are responsible for choosing the evening meal, and a menu file contains pictures of various meals to help them make this choice, although the deputy manager stated that residents can choose an alternative if they prefer. Meals are prepared by staff with the support of residents. The cupboards, fridge and freezer were seen to contain a variety of nutritious foods for consumption. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. This judgement has been made as the feedback received from health and social care professionals indicates that resident’s needs are met. Good developments have also been made to the medication system, though further improvements are needed. EVIDENCE: The health and social care professionals associated with the service commented that the home maintains good partnership links with them, with one adding that: “…I feel positive about the work we have to complete over the next year by working in partnership with each other…”. The professionals surveyed felt that the home communicates well, and that the health and social care needs of the residents are met by the home. The home maintains a record of all healthcare appointments of each resident providing details of the treatment, outcome and when the next appointment is due. A review is carried out annually with the social worker, staff and resident, where any major health issues, changes, events and the resident’s emotional well-being are discussed and planned for. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 14 The previous inspection identified a number of requirements needed to improve medication administration at the home. Improvements have been made to ensure that medication is appropriately labelled, a record is maintained of staff signatures and there is a record of all medication held at the home. The care plan for each resident contains detailed information about the medication that they take, the reason they have it and how it might affect them. Improvements are needed to ensure that the medication administration record corresponds with the labels on the medicine container, and it is recommended that this is audited every month when the new chart is generated. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 and 23 Quality in this outcome area is good. This judgement has been made as residents feel confident to raise areas of concern they have and systems are in place to reduce the risk to residents. EVIDENCE: The home has the MENCAP complaints procedure that provides guidance on how to deal with complaints and the different stages of investigating a complaint. A record is maintained of informal complaints received and any incidents involving residents, along with the outcome of this. When one resident was asked if they knew how to make a complaint they responded by saying: “…yeah, yeah…talk to staff…”. Staff records indicate that they have received recent training in adult protection, so to minimise the risk to residents. There are also policies and procedures in place regarding abuse awareness and what to do in the event of this. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is adequate. This judgement has been made as the home is comfortable, yet areas of redecoration are needed to be addressed. EVIDENCE: The previous inspection required that a number of areas in the environment be addressed. The manager stated that some progress has taken place to improve the environment, such as new cookers and new windows. A tour of the building indicated that some areas, such as the lounge, are in need of re-decoration, as they looked ‘tired’ and worn. These include the toilet on the top and first floor, where there is chipped paint and stained lino, along with the lounge carpet that needs cleaning as it is stained in areas. In the dining room wallpaper was observed to be peeling off above the radiator. The requirements to address the décor have been restated on previous inspections and on this occasion will be restated. However, if the home fails to meet the requirements within the timescale given then enforcement action may be considered by the CSCI. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 17 Two residents bedrooms were seen to be clean and individually decorated to personal preference. The home was also cleaned to a good standard throughout, bright and freshsmelling in all areas. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made as staff have training for their role and appropriate recruitment checks are carried out to minimise the risks to residents. EVIDENCE: The home holds recruitment information on each member of staff. Two staff files were examined and found to contain relevant information such as proof of identification, correspondence relating to offer of job, two references, POVA First check and a record of the interview of staff. There is a new deputy manager at the service who spoke about their induction and how they are looking at developing their competencies over the next six months. Records indicate that all new staff are supported through an induction and probationary period and all staff receive ongoing support through supervision. Staff files also contain copies of certificates of training courses undertaken, including fire safety, first aid, protection from abuse and manual handling. The manager spoke about how the service had recently received additional funding to enable the staff complement to increase to having three staff on each morning shift. He stated that this is to accommodate the increasing 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 19 needs of the residents in relation to their ageing. This has also allowed for increased one-to-one work and enabling staff to take residents out. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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): 37, 39, 40 and 42 Quality in this outcome area is good. This judgement has been made as there is a committed and competent manager at the home. The health and safety of residents is ensured through regular health and safety checks. EVIDENCE: One staff member commented of the manager: “…he’s a great teacher…very professional…”. Observations and discussions with the residents and staff during the inspection were positive, indicating that the manager is respected and well-liked by the those living and also those working at the home. The manager also discussed that his new line manager is supportive in negotiating with outside agencies to develop the service for the benefit of the residents. Since the last inspection improvements have been made, where the CSCI receives reports of monthly visits by the line manager. Currently the front 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 21 sheet is sent to demonstrate these visits are carried out, and it is recommended that the full report is provided to the CSCI. The home maintains records to demonstrate that appropriate health and safety checks are carried out on the fire system and equipment, fridge and freezer temperatures and water temperatures, gas safety and legionella prevention checks, etc. Risk assessments are also in place for when residents are travelling in the home’s car, and also for activities carried out by staff such as replacing light bulbs or using the step ladder. The home holds a weekly residents meeting, and the records demonstrate the involvement of all the residents in suggesting ideas for the weekly menu, trips out and discussion around what they have recently done. There are also regular staff meetings held at the home. 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 23 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) Requirement The Registered Persons must ensure that the medication administration record corresponds with the labels on the medicine container. The Registered Persons must ensure that: 1. The repair and decorative needs are addressed (as indicated on page 17 of this report) 2. There is a regular programme of maintenance so that repair and decorative needs to not remain outstanding for unacceptable periods of time. (Previous timescales not met) Timescale for action 31/10/06 2. YA24 23(2)(b) 31/12/06 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 Page 24 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 YA20 Good Practice Recommendations The Registered Persons should ensure that the medication administration record is audited monthly to ensure it corresponds with the labels on the medicine containers. The Registered Persons should ensure that the full report of monthly visits by the line manager are sent to the CSCI. 2. YA39 20, Glamorgan Road DS0000017365.V307052.R01.S.doc Version 5.2 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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