Inspection on 21/02/06 for 23 Pierrepoint Road

This inspection was carried out on 21st February 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 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 15/08/05

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 23 Pierrepoint Road Acton London W3 9JJ Lead Inspector Mr Ged Durkin Unannounced Inspection 21 February 2006 01:30 st 23 Pierrepoint Road DS0000027748.V278013.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 23 Pierrepoint Road DS0000027748.V278013.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. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 23 Pierrepoint Road Address 23 Pierrepoint Road Acton London W3 9JJ 0208 896 2581 0208 993 2280 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.caremanagementgroup.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 DS0000027748.V278013.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 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 DS0000027748.V278013.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3 and one quarter hours. The Inspector spoke with the Deputy Manager and one Senior Support Worker. The Inspector spoke with five service users. The atmosphere in the home was initially quiet and calm but as the afternoon went on the atmosphere changed as some service users noisily interacted with each other Some service users were engaged in activities with staff. Staff were observed to interact with service users in a pleasant and sensitive manner. 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. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 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 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 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 The home ensures that prospective service user’s individual aspirations and needs are assessed in a satisfactory manner. EVIDENCE: The Inspector was informed by senior staff that CMG has its own assessment team who have an overview as to where in the organisation there are vacancies. When a referral is made then staff members from the home in which there is a vacancy are contacted and then an assessment is undertaken. This involves written assessments from placing authority, visits to the prospective service user, the care manager/family/ and prospective service user visiting the home, which may then lead to overnight stay before leading on to, if everyone is in agreement, to an extended trial period. There is then a placement review meeting after this trial period to determine whether to make this placement permanent. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 8 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 Care plans and risk assessments are detailed and comprehensive and staff try to ensure that service users are enabled to make decisions about their lives on an ongoing basis. EVIDENCE: The Inspector viewed two service user plans, which were detailed and comprehensive and covered areas of need such as assessments, reviews, medical information and financial matters. In addition, every service user has a daily record written by staff after every shift and the home has a key worker system in place. Service users are helped with decision making on a daily basis by staff in areas such as choice of clothing and menus. The home has monthly service user meetings in which service users are updated of planned events or staff changes. Risk assessments viewed by the Inspector were detailed and reviewed on a monthly basis. Staff also signed as evidence that they had read and understood the risk assessments made on individual service users. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 9 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): 15, 16 and 17 Service users are facilitated by staff to have on going appropriate family and personal relationships. Service user’s rights and responsibilities are recognised and respected on a daily basis by staff. Service users also are offered a choice of meals that they enjoy. EVIDENCE: The majority of service users have family but amount of contact can vary. The home has unsuccessfully, so far, applied to local agencies to obtain befrienders or advocates for some service users. All the service users are on the electoral register and two service users voted in person at the last general election. Four other service users used the postal vote system. Post is given by staff to service users to open and service users are able to make and receive calls in private, either by use of the office phone or pay phone. Service users get a choice of meals and are asked in the morning as to what meals they want for the rest of the day. The kitchen was well stocked with food. All meals are prepared by care staff who have appropriate food preparation training. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 10 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 and 21. Service users receive personal care on an individual basis and in accordance with their wishes. The health needs of the service users are well monitored and met and the home has safe systems and storage of medication. Individual service user’s wishes are being sought in a sensitive manner with regard to death and dying. EVIDENCE: The vast majority of service users need varying degrees of support with personal care. Particular assistance is given to service users in grooming. A hair dresser comes to the home on a weekly basis. The personal appearance of the service users is monitored by staff on an ongoing basis. Continence management of particular service users is handled in a sensitive manner by staff. Staff were able to give a detailed explanation of individual service user’s routines and how they ensured that service users received their personal care in accordance with their wishes. Skin care is given a particular priority by staff and body charts are used to identify any areas of concern. All service users are registered with a local GP. A number of service users have a variety of medical conditions that require regular monitoring but remain well controlled. Staff spoke of the very good level of support the home receives from community based medical professionals. The home uses a monitored dosage medication system. All staff are trained before administrating medication and have six monthly updates. Medication is 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 11 stored in a purpose built secure cabinet. The Inspector examined all the service user’s medication administration sheets. All were in order with no gaps. Work has begun with service users and their families to identify individual service user’s wishes in the event of their death. 23 Pierrepoint Road DS0000027748.V278013.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): 22 and 23 The home ensures that service user’s views are listened to, and if possible, acted upon. There are satisfactory systems in place to ensure that service users are protected from abuse. EVIDENCE: The home has monthly service users meetings, which are forums for service users to make their views known. Each service user has a key worker and will have key worker sessions, which are another opportunity to express their views. Staff also interact with service users on a daily basis and will try to ensure that any opinions expressed are listened to and acted upon. The home has a clear complaints and adult protection policy. Staff had a clear understanding about “Whistle blowing” and what action they would take in the event of them witnessing any form of abuse. The Inspector checked two service user’s personal monies held in the office for safekeeping. Both amounts of money tallied with the financial records and there was a good record of what was spent with accompanying receipts. These are checked on a daily basis. Service user’s bank statements were also kept in the home. Two staff members are co-signatories to individual service user’s accounts. These accounts are checked on a weekly basis by the Registered Manager and her deputy. 23 Pierrepoint Road DS0000027748.V278013.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): 25, 29 and 30. Service users live in a comfortable, clean environment that meets the needs of those who live there. EVIDENCE: The Inspector viewed two service user’s bedrooms. Both demonstrated a high level of personalisation. The home is not purpose built but has been adapted to meet service user’s needs. New specialist baths have recently been installed. There are grab rails around toilets, which also have raised seats. The home has recently built a studio type apartment for one service user to enhance his/her opportunity to develop their independence skills with staff support. The home was clean and hygienic on the day of the inspection. The home has a part time domestic staff member who works Monday to Friday. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 14 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): 33 and 34 Service users are supported by an effective staff team, who receive appropriate support and supervision and who have been subject to satisfactory recruitment practices. EVIDENCE: Currently there are three care staff in the morning and three care staff in the afternoon. The Registered Manager works approximately 9 am-5 pm. There is one waking and one sleep in staff member at night. The Inspector was informed by staff of the intention to increase staffing levels to enable more external activities to be carried and to ensure that service users, the majority are over 65, needs are met. The Inspector viewed two staff records and found all necessary documentation in place. There are monthly staff meetings and all staff receive monthly staff supervision along line management responsibilities. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 15 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 and 42. Service users benefit from a well run home in which health and safety is promoted and prioritised. EVIDENCE: On the day of the inspection the home appeared to be running smoothly. Service users were engaged in various activities and staff were engaging and interacting with them both in a group setting and on a one to one basis. Staff were also observed to carrying out other duties such as serving tea, writing reports, dealing with service user’s money and generally going about their work in an unobtrusive manner. Staff explained about the need to make interventions between certain service users because of their tendency to argue and nosily disagree with each other. This was evident as the afternoon progressed and staff made appropriate interventions in order to minimise verbal hostilities between service users. There are regular handovers between shifts and a communication book as an additional means of ensuring information is relayed effectively. There is also a monthly staff meeting that provides an opportunity to relay information and allow staff to discuss issues. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 16 The Inspector checked a number of health and safety records that included fire prevention and fighting measures, hot water temperatures, legionella tests and the contents of the first aid box. The home has its own designated health and safety person who undertakes a monthly health and safety audit that also covers maintenance issues. 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 17 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 x 4 x 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 x 25 3 26 x 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 x 36 3 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 x 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x x x x 3 x 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 23 Pierrepoint Road DS0000027748.V278013.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection West London Area Office 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. 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