Inspection on 09/02/06 for 65 Charlton Road

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

65 Charlton Road 11/01/07

65 Charlton Road 09/08/05

65 Charlton Road 13/12/04

65 Charlton Road 06/05/04

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 65 Charlton Road 65 Charlton Road Kenton Middlesex HA3 9HR Lead Inspector Sue Mitchell Unannounced Inspection 9th February 2006 15.30 65 Charlton Road DS0000017527.V282283.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 65 Charlton Road DS0000017527.V282283.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. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 65 Charlton Road Address 65 Charlton Road Kenton Middlesex HA3 9HR 0208 204 2191 020 8204 0020 general.enquiries@heritagecare.co.uk www.heritagecare.co.uk Heritage Care 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) Daphne Gayle Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: 65 Charlton Road is a care home providing personal care and accommodation for up to 7 people who have a learning disability. The people living at the home at the time of the inspection were all female, though the service is not gender-specific. There was one vacancy at the time of the inspection. The registered provider of services at the home is Heritage Care, a national notfor-profit organization operating since 1993. Paddington Churches Housing Association owns the building. The home is located within a residential area of Kenton, within the London Borough of Harrow. It is around ten minutes walk from shops, pubs, parks and bus links. The home has a driveway that can take about five vehicles, including the house van. Parking restrictions do not apply on the road outside the home. The home was opened in 1998. It is a twostorey building that was purpose built for residential care. It blends in reasonably with surrounding homes. All the homes bedrooms are single, all fully furnished with built-in sinks. The home has two bathrooms and two shower rooms, all of which have toilets. One further toilet is available on the ground floor. Access to the first floor is by stairs or a lift. The home has a kitchen/diner, a main lounge focused around a TV and DVD, and a small second lounge available for more private use. The home has a reasonably sized garden, much of which is paved for easier access. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out during the late afternoon and early evening when the residents came back from their day centres. There was one resident in the home and the manager was on duty when the inspector arrived. Three support workers were on duty for the evening shift with the six residents. The inspector spent some time chatting with all the residents during the course of the inspection. All but one person was able to speak about their day and their recent social activities. Some of the residents have some communication difficulties but staff were observed to be able to understand their speech and responded to them in a caring manner. Staff and residents were observed to have an easy relationship with each other chatting to each other about what happening and planning for future events. The inspection focused on following up on the last inspection’s requirements, looking at care plans, risk assessments, health and safety and staffing matters. Four comment cards had been received from two residents and two relatives/ friends. The inspector would like to thank the staff and residents for their participation in the inspection. What the service does well: What has improved since the last inspection? The home had met all of the last inspections requirements within the stated timescales. The staff vacancies had been filled and the new staff were in post. The deputy post was in the process of being advertised. Staff have now had training on Person Centred Planning, which will be implemented with the residents during the coming year. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this occasion, as there have been no new admissions to the home since the last inspection. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9 The residents care needs are regularly reviewed and updated with them to ensure that their goals and wishes are supported by staff. Staff encourage the residents to take appropriate risks and support those that need help to lead an independent lifestyle EVIDENCE: Two care files were sampled. These were found to be comprehensive and in general contained relevant up to date information such as reviews, care plans, monthly summaries. The manager should ensure that key workers regularly update information in the files. The key workers compile monthly summaries. It was recommended that a section on changes/progress/outcomes on care plans/goals should be added to the summary sheet for monitoring purposes. The individual files were noted to be bulky making it difficult to access current information easily. It was recommended that key workers compile working care plan folders that contain just current working documents on each resident and use the main file for archiving. The care plan folders should contain care plans, the last review, monthly summaries, risk assessments and behavioural management or other guidelines and any other information that staff need to use on a day-to-day basis. The manager informed the inspector that all staff 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 10 have had training on using Person Centred Planning and the home hopes to start using this format during the year with the residents. The risk assessment for one person sampled was found to be out of date (last reviewed 12/04) The manager must ensure that risk assessments are reviewed on a regular basis and any management or handling guidelines are updated at the same time. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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): 12,15,16 The residents lead active and fulfilling social lives and are encouraged to keep in contact with friends and family. Staff respect the residents rights and encourage them to take responsibility for managing their own lives as much as possible. EVIDENCE: The inspector spoke to all but one of the residents about their activities both in and out of home. Two residents spoke about their friendships with people from other homes and the day centres. Three also spoke about their contact with their relatives and close family, about their visits home and from their family to the care home. The manager stated that all the residents have close regular family contact and that families are invited to social events in the home. The residents also spoke about a disco they had attended the previous evening, which they had enjoyed. One person spoke enthusiastically about her holiday to Memphis to visit Elvis Presley’s home in Graceland last summer. Another resident spoke about the plans for the next holiday and expressed a wish to go to Pontins near to the New Forest. All but one person attends a day centre. The residents told the inspector about their day there and what they had done and about the friends they had there. One person who is elderly stays at home with the staff and goes out with them and has visits from 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 12 relatives as well. This person has a pet bird in her room, which keeps her company, she also said she enjoyed watching TV and looking at magazines and newspapers. The monthly summaries and care plans indicated the type of activities the residents liked and attended. They attend a number of local clubs in the area; go to the cinema, restaurants, shopping etc. The manager had been required to ask the residents if they wanted a key to their rooms. Only two had keys and one had a front door key, The manager said none of the others wished to have a key. The residents have access to the house phone, which is cordless, to make or receive calls when they wished. Staff were observed to knock on the residents bedrooms doors. Staff were also observed to interact with the residents during the course of the inspection, chatting to them at the mealtime and in the lounge. They were respectful in requesting the residents if they wished to have help to have personal care. There was clearly a relaxed atmosphere in the home with both staff and residents being at ease with each other. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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): 19,20 The residents are supported by staff to attend their health care appointments. Medication practices are safe EVIDENCE: The care files sampled contained clear details of all health care appointments attended by the residents. There was a record of the health care professional/ consultant seen and outcomes of the appointment. The home has now purchased weighing scales as recommended at the last inspection. There had been two outstanding requirements relating to the medication standards, which were assessed on this visit. These have now been met. The manager gave the inspector a draft copy of the homes medication policy to the inspector, which was forwarded to the CSCI pharmacy inspector for her comments. Residents allergies are now being added to the MAR sheet as required. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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 the following standard(s): 22 The residents, their families and friends are aware of the homes complaint policy. EVIDENCE: There had been two complaints made to the home by a service user from another home about one of the residents in Charlton Rd. There was a detailed record of this person’s complaints, which were also reported to CSCI. The manager informed the inspector of the action taken so far and how the staff were supporting both service users. None of the residents expressed any dissatisfaction with the care provided. A comment card from a volunteer driver stated that he had no concerns about the home. One of residents responded that she was very happy living in the home and liked the staff and she knew to whom she could complain. One resident had made an allegation about a staff member, which was referred to the Harrow POVA team. This was investigated and found to be unsubstantiated. As a result of the investigation there were clearer guidelines for staff in managing this service user’s care, which were seen in the care file. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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 the following standard(s): 27,29 The residents have access to appropriate bathing and washing facilities, which meet their varied needs. The home ensures that the residents are provided with the specialist equipment that they need EVIDENCE: The inspector did not tour the premises on this occasion. She was invited to go into a couple of the resident’s rooms for a chat and found them to be comfortably furnished with the resident’s personal possessions, ornaments and photos etc. The home had been required to ensure that repairs and refurbishment to the shower rooms were carried out within the stated timescales. The repairs and refurbishments to the shower rooms were inspected and found to have been completed in full. The manager stated that the kick panels on the doors and skirting boards were due to be repaired. Quotes for automatic door opening to the resident’s bedrooms were being sought at the time of the inspection. These last were recommendations from the last inspection The manager had been required to contact the occupational therapist to come and carry out an assessment of the equipment currently used by the residents in the home. The manager stated that a referral had been made and that the OT had visited recently and had given verbal feedback regarding the equipment. She had said that the equipment was appropriate for the current 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 16 resident group. It was recommended that the manager write to the OT to ask for written feedback. 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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 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): 32,35 The residents are supported by a stable staff team who have received a range of appropriate training to meet the resident’s needs. EVIDENCE: The manager stated that the deputy post was to be advertised shortly and that recruitment to all but one vacant post had taken place and staff were now in post. The manager stated that the vacant post would be recruited to when the current resident vacancy was filled. The home uses the organisation’s bank staff to cover for leave etc. At the time of the inspection there were three staff on the afternoon shift, which corresponded to the rota. One staff member was bank staff but said that she worked regularly in the home and spoke knowledgably about the residents and their needs. The manager stated that one person had now completed NVQ2 and three had started the course the previous day. Three more staff would go on the course during the next financial year. Other training courses undertaken since the last inspection were: POVA. Moving and handling and person centred planning 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 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 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): 42 The residents live in well maintained and safe environment. EVIDENCE: The certificates relating to the equipment and appliances used in the home were made available for inspection. These were noted to be up to date. Fire safety checks and call bell test records were in place and up to date. The last fire drill was in January 2006. The fire risk assessment was in need of updating. Staff last had fire safety training in 2004. The manager must ensure that staff receive updated fire safety training and that the fire risk assessment is updated 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X X X X X X 2 X 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 20 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 YA9 Regulation 13.4(b)(c) Requirement The manager must ensure that risk assessments are reviewed on a regular basis and any management or handling guidelines are updated at the same time. The manager must ensure that staff receive updated fire safety training Timescale for action 15/03/06 2 YA42 23.4(d) 01/04/06 3 YA42 Wrkplace The fire risk assessment is Regs(1997) updated 31/03/06 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 21 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 YA6 Good Practice Recommendations It is recommended that the individual service user files be checked through to ensure that key documents such as individual plans and risk assessments are easily available and are the most up-to-date versions. It was recommended that a section on changes/progress/outcomes on care plans/goals should be added to the summary sheet for monitoring purposes It was recommended that key workers compile working care plan folders that contain just current working documents on each resident and use the main file for archiving. The care plan folders should contain care plans, the last review, monthly summaries, risk assessments and behavioural management or other guidelines and any other information that staff need to use on a day-to-day basis. It is recommended that the standard menu from November 2004 be reviewed to reflect the current season and any revised tastes of service users. (Not assessed on this occasion) It was recommended that the manager write to the OT to ask for written feedback on the outcome of the visit made to assess equipment within the home. 2. 3 YA6 YA6 4. YA17 5 YA29 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 65 Charlton Road DS0000017527.V282283.R01.S.doc Version 5.1 Page 23 - 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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