Inspection on 15/08/05 for 23 Pierrepoint Road

This inspection was carried out on 15th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

23 Pierrepoint Road 14/06/07

23 Pierrepoint Road 21/02/06

23 Pierrepoint Road 15/02/05

23 Pierrepoint Road 02/08/04

23 Pierrepoint Road 02/02/04

23 Pierrepoint Road 18/07/03

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 23 Pierrepoint Road Acton London W3 9JJ Lead Inspector Gavin Thomas Unannounced 15 August 2005 at 1.30pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 23 Pierrepoint Road Address Acton, London W3 9JJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8896 2581 020 8993 2280 info@cmg-corporate.com Care Management Group Limited Ms Jennifer deBurgh Bradley Care Home 13 Category(ies) of Learning Disability (0), Learning Disability, over registration, with number 65 years of age (0) of places 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No Date of last inspection 15 February 2005 Brief Description of the Service: 23 Pierrepoint Road is a care home registered for thirteen adults with a learning disability, who may be over the age of sixty - five. The home is owned and managed by Care Management Group Ltd, an organisation who became established in 1995. This establishment is a large detached house in central Acton. It is not purpose built, but the building has been adapted to meet service users needs. Service users bedrooms are situated on all floors. There are bathroom and toilet facilities on all floors. The home has a passenger lift to all floors. The home has a large dining area a comfortable communal lounge. There is also a separate activities room and a well maintained rear garden. One of the homes main aims is to assist individuals to enhance and develop their independence skills where possible. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4.50hrs. The Inspector spoke with the Registered Manager, the Deputy Manager and one Senior Support Worker. The Inspector also spoke with four service users and two staff members. The atmosphere in the home was calm and homely. All service users spoken to said they were happy and well. Staff were interacting with service users in a pleasant and professional manner. Some service users were engaged in activities with staff. This included tabletop games, menu planning and setting the tables for the evening meal. What the service does well: What has improved since the last inspection? The senior team had strengthened since the last inspection. A Deputy Manager had been appointed and senior staff had also been appointed. The Registered Manager was in the process of training the Deputy Manager and Senior Support Workers to take on specific roles and responsibilities. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 6 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. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 4 & 5 The Statement of Purpose and Service User Guide were well written and contained a wealth of information about the service. Robust procedures were in place for introducing and admitting prospective service users to the home. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The Statement of Purpose was in the process of being updated. The Registered Manager said there had been no changes to the Service User Guide. The Registered Manager confirmed that all prospective service users are encouraged to visit the home prior to admission. Written contracts were in place between the home and all service users. Where possible, service users sign their contracts. The contracts examined were comprehensive and included the criteria as set out in standard 5.2 of the National Minimum Standards for Care Homes for Adults (18-65). A service user had signed one of the contracts examined. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 The quality of care plans, associated documents and risk assessments was good. Care planning processes are consistent. Staff are provided with the information they need to satisfactorily meet service users’ needs. EVIDENCE: Care plans were in place for all service users. The contents of care plans examined were very specific to service users needs and how these needs are met. Senior staff explained that the implementation of care plans is monitored via observations, discussions with staff in team meetings and discussions with service users. The Registered Manager explained that the new care planning methodology was in the final stages of being piloted. Care plans are reviewed every six months. Risk assessments were in place for all service users. Risk assessments examined were very well maintained and updated regularly. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 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 standard(s) 12, 13 & 17 The home does well in providing service users with a variety of meaningful and constructive activities. Links with the community are good and well maintained. Recent investment in a mini bus with adaptations to accommodate wheelchairs is a good way to enable some service users to comfortably access community-based activities. Meals served in this home are good, offering choice and variety. EVIDENCE: The majority of service users are now reaching /or at a pensionable age. However, service users are still encouraged and supported to participate in meaningful activities. One service user was in paid employment. A programme of activities was in place. The home has introduced a wider range of in house activities such as arts and crafts, foot spas and puzzles. The Registered Manager said that the home was also in the process of purchasing a keyboard to increase the types of music activities currently being offered to service users. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 11 The home has a room on the ground floor, which is used, for activities and recreational purposes. Service users continue to integrate with service users from other homes in the West London area owned by Care Management Group. Service users preferred activities in the community were set out in their care plans. The home now has the use of a new mini bus. Care Management Group owns the mini bus. The mini bus is fitted with adaptations to accommodate up to three wheel chairs. Serviced users access a range of community based activities and places of interest including parks, museums, sporting venues, shops and restaurants. The Registered Manager said that the home was in the process of exploring additional community based activities for service users to choose from. At the time of this inspection, some service users were relaxing after lunch, staff were interacting with some service users with tabletop games and some service users were out in the community. Menus examined indicated that service users are offered a wide range of wellbalanced meals. Service users are encouraged to contribute towards the menu. The Inspector observed one serviced user planning the menu with the staff team. One service user attends cookery classes away from the home. The service user showed the Inspector a record of all the dishes they have learnt to cook in these classes. The service user was very enthusiastic about the cookery classes. The provisions for the storage of frozen, chilled and dried foods were satisfactory. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 & 21 Personal support in this home is offered in ways, which promotes service users’ privacy, dignity and independence. The health needs of service users are well met with evidence of good multi disciplinary work taking place. EVIDENCE: Service users personal care and support needs were clearly set out in their individual plans of care. The Registered Manager said there have been no changes to external professional support. The home is supported by the CTPLD (Community Team for People with Learning Disabilities). Service users are accompanied by staff when they shop for toiletries, clothing and other personal requisites. All service users have a key worker. When necessary, the Registered Manager is key worker to some service users. The Registered Manager confirmed that three staff had attended training on promoting personal hygiene in February 2005. Staffing resources are provided in accordance with service users needs. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 13 The Registered Manager confirmed that service users health needs were being managed with support and guidance by members of the CTPLD, such as the Speech and Language Therapist and Clinical Psychologist. Specialist health treatments are accessed via referrals by the GP. The District Nurses visits the home when required. All service users have an annual health check. Primary health care treatments are arranged by the home. These include dentistry, opticians and chiropody. Appropriate action is taken in response to any changes in service users health. A draft policy on the ageing process was in place. This policy was generated in June 2005. Where possible, service users last wishes are recorded. The Registered Manager explained that progress towards this sensitive matter is very gradual. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The home has a satisfactory complaints system in place. Good practice systems were in place for the safety and protection of service users both inside and outside the home. EVIDENCE: A complaints policy and procedures were in place. One complaints procedure was written for the benefit of visitors. Staff may also use this. Another complaints procedure was written specifically for service users. A record of complaints was in place. The home had received one complaint since the last inspection. This was an internal complaint. The Registered Manager said that this complaint was still under investigation at organisational level. Adult protection policies and procedures were in place. The home was also in receipt of the Department of Health – No Secrets guidance document and a whistle blowing policy. Staff last attended adult protection training in July 2004. Refresher training has been arranged for this year. The Registered Manager, Deputy Manager and one Senior Support Worker said there were no known concerns with regards to service users safety or protection. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 & 30 The standard of the environment within this home is good, providing service users with a comfortable and homely place to live. EVIDENCE: The home is in keeping with local ambience. The home was clean and well presented. A programme of routine maintenance was in place. The home had installed two new boilers, two new baths and a new cooker since the last inspection. The Registered Manager explained that replacement furniture for the dining room was still under discussion with service users. Building work had commenced to convert the disused garage to the rear of the home into a studio apartment for one service user. This conversion when complete will form part of the registered property. This service will give one service user the opportunity to develop their independence skills with staff support. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 16 Much discussion took place about the intended use of the studio apartment. As a result of this discussion, it was identified that Care Management Group would need to make application to the CSCI to register this part of the property. The home was also asked to consider external health and safety matters such as providing an enclosed walkway to link the studio apartment with the main home. The Registered Manager confirmed that planning permission had been approved by the local council for this conversion. The home has a total of five toilets and four baths. The two new baths installed in July 2005, are walk – in baths. The Registered Manager said that these baths are proving to be very successful with service users who did not feel safe in getting in and out of ordinary baths. A separate toilet is provided for staff and visitors. A policy on the control of infection was in place. Hand washing facilities are prominently sited throughout the home. Liquid soap and disposable paper towels are provided in all bathrooms and toilets. Documentary evidence was not available to confirm that the washing facilities and service complies with the Water Supply (Water Fittings) Regulations 1999. This information was obtained subsequent to this inspection and supplied to the CSCI on 23 August 2005. A legionella test was carried out in November 2004. The results of this test were satisfactory. This test is due to be carried out again in November 2005. The Registered Manager said there were no changes to the C.O.S.H.H policy and procedures. The home has one domestic member of staff who works from Monday to Friday every week. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 36 Staff morale in this home is generally good, resulting in an enthusiastic workforce, who works positively with service users to maintain a good quality of life. Aspects of specific induction training must be evidenced. EVIDENCE: Training and development programmes were in place. The home’s training programme is generated from the training schedules issued by the organisation’s training department. There was no evidence of induction, foundation and LDAF (Learning Disability Award Framework) training. This must be obtained. The home was making good progress towards staff training and development assessment and profiles. Formal supervisions are carried out every one to two months. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 & 42 The Registered Manager demonstrates a commitment to empowering and supporting both service users and staff. The Registered Manager has a clear development plan and vision for the home. The management of this home is satisfactory. Good practice systems were in place for reviewing the home against its performance. Health and safety systems examined were well maintained. EVIDENCE: The Registered Manager has been in her current post for four years. The Registered Manager said she was working towards the Registered Manager’s Award. The Registered Manager said she is well supported by a team of senior staff. The home also has a stable staff team. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 19 The Registered Manager operates an open door policy and demonstrates a commitment to ensuring that the needs of service users are met both as individuals and as a group. Progress was being made towards the development of quality assurance and monitoring systems. The Registered Manager explained that surveys would be distributed to service users and significant others by October 20045. The results and outcomes of the surveys would be presented at the service users annual forum hosted by Care Management Group and the service users newsletter. Care Management Group was still in the process of devising a staff newsletter. The Registered Manager was in the process of reviewing the home’s business plan and the home’s annual development plan. Subsequent to this inspection, a review of the business plan was supplied to the CSCI. This service was assisting Care Management Group with the piloting of new quality assurance systems. Service users meetings and staff meetings are held separately on a monthly basis. The Inspector saw the records of minutes for these meetings. Staff handovers take place between each shift. Health and safety audits are carried out monthly. Internal health and safety meetings are held when necessary. Health and safety checks and monitoring systems were well maintained. The following records were examined and found to be in order. • Health and safety risk assessments. • Fire risk assessment. • Fire drill log. • Routine fire safety checks. • Weekly fire checks. • Electrical checks. • Hot water temperatures. • Accident record. • Health and safety monthly checks. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 20 A valid gas certificate was not available for inspection purposes. Subsequent to this inspection, the Registered Manager confirmed that the annual gas check for this year is due to be done on 25 August 2005. Staff • • • had attended relevant health and safety training as follows: First Aid. Food hygiene. Moving and handling. The contents of the First Aid kit were satisfactory. Health and safety policies and procedures were in place. These were updated in March 2005. 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 21 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 x x 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 23 Pierrepoint Road Score 3 3 x 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 22 No 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 35 Regulation 18(1)(a) Requirement The home must obtain evidence of induction, foundation and LDAF (Learning Disability Award Framework) training. Timescale for action 30/9/05 2. 3. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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 23 Pierrepoint Road G61-G10 s27748 23 Pierrepoint Road v214213 150805 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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