Inspection on 06/06/05 for 89-91 Bessborough Road

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

89-91 Bessborough Road 22/05/07

89-91 Bessborough Road 19/04/06

89-91 Bessborough Road 10/02/06

89-91 Bessborough Road 13/01/05

89-91 Bessborough Road 10/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 89/91 Bessborough Road Harrow Middlesex HA1 3BD Lead Inspector Richard Adkin Unannounced 6 June 2005, at 13:00h00 th 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. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 89/91 Bessborough Road Address 89/91 Bessborough Road Harrow Middlesex HA1 3BD 020 8423 1116 020 8864 4191 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) Harrow Consortium for Special Needs CRH PC Care Home only 12 Category(ies) of MD Mental Disorder registration, with number of places 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 13 January 2005 Brief Description of the Service: 89 - 91 Bessborough Road is a care home for up to 12 adults who have enduring mental health problems and require medium to long term support. The home is run by Harrow Consortium for Special Needs (the registered providers), staffed by the Family Welfare Association, and with premises supplied by Paddington Churches Housing Association. At the time of inspection there were two service user vacancies The home is situated on a busy link road to Harrow that includes bus links. It is fifteen minutes walk to Harrow town centre where there are shops, leisure facilities and further transport links. There is space for two cars to park on the forecourt, and there is unrestricted but regularly-used parking on the road. The home is made up to two interlinked semi-detached properties that span three floors. Access is by stairs only. Bedrooms are situated on the 1st and 2nd floors. Each service user has their own single room. The ground floor has communal living and dining rooms, a new conservatory, a laundry room, and office space. There is a well kept garden at the rear of the property. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over four hours on a midweek afternoon with the focus of looking at the requirements from the previous inspection that took place on 13 January 2005. The Inspector looked around the building and a number of records and policies were inspected. The Inspector met 4 residents during the course of the inspection and five staff. The Inspector would like to express his thanks to everyone at the home for their contribution to the inspection. What the service does well: What has improved since the last inspection? Progress on redecoration is slow but since the last inspection work has commenced on the outside of the building and is in the process of commencing on the inside of the home. Likewise furnishing in the residents’ rooms will be improved following an audit. Staff have undertaken Protection of Vulnerable Adults training. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 Limited progress has been made in having a ‘Statement of Purpose’ and ‘Service User Guide’ available in the office or being given to residents. Without this there is no clarity of intent. EVIDENCE: A carefully tailored plan was in place for a service user having a trial stay at the Home and looked at by the Inspector. However there was no ‘Statement of Purpose’ or ‘Service User Guide’ accessible within the office or evidence that a ‘Service User Guide’ had been given to each resident. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 Residents’ individual plans need to be more integrated to ensure that residents’ individual needs are addressed. EVIDENCE: Two residents’ files were looked at by the Inspector. There was a strong positive user focus in a recently developed format for residents’ individual plans; however the views of the care staff, home or that of the multidisciplinary team involved in the delivery of the CPA were not being integrated into these plans making them incomplete. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 and 17 Residents are integrated into local well developed day services. Meals are nutritious and balanced and offering a healthy and varied diet for residents. EVIDENCE: A number of residents were out at a range of day services during the course of the inspection and this was also detailed in care plans looked at. The Inspector observed the availability of a large choice of fruit, and also a good range of fresh vegetables. There was a choice of meat or vegetarian option for each meal and culturally appropriate food choices. Food in the fridge was appropriately labelled and dated. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 11 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) 20 Limited progress has been made in protecting residents by the Home’s policies and procedures for dealing with medicines. These shortfalls are potentially detrimental to the welfare of residents. EVIDENCE: A sample of PRN medication was looked at by the Inspectors, some did not have clear guidance for its use by the GP for staff. There was missing medication for one service user – it subsequently transpired that this was an error on the MAR sheet. The medication trolley was not secured and the CSCI Pharmacy Inspector’s last report was not available. The senior on duty kindly advised the Inspector that serious consideration was being given to changing the pharmacy which would tackle some of the medication issues that were arising. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 standard(s) 23 There is a lack of a comprehensive Adult Protection Policy does not ensure that people living in the home are protected from abuse. EVIDENCE: Since the last inspection staff teams have received training in protecting vulnerable adults from abuse. There are shortcomings in the home’s adult protection policy including response times and targets, comprehensive reference to local borough adult protection protocols, and inaccurate information about reporting to the Commission for Social Care Inspection. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 standard(s) 24 and 28 Some improvements to the décor have been made and others are in the process of happening. EVIDENCE: The home had scaffolding on the outside at the time of the inspection for outside decorating; necessary works were on the point of being undertaken inside the Home. Carpets were in urgent need of replacement. Communal areas were bright and friendly and a hub for interaction within the home. It would be useful for the registered provider to give thought to personal safety and risks within the home given the complex layout of the home. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35 The deployment and number of staff available from mid-evening to early morning is not sufficient to meet the needs and risks presented by residents. EVIDENCE: The staffing levels between 8.30 pm and 9 am need to be reviewed. There is only one member of staff on duty during that time, with another member of staff on call at home. This needs to be reviewed and justified by the registered provider. A training and development plan for the staff group needs to be implemented and given some sense of direction. Agency staff need to have training profiles like other members of staff. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 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, 40, 41 and 42 The Home does not have a registered manager. The registered provider needs to ensure that staff are given direction, leadership and guidance to provide consistent quality care and systems for the benefit of residents. EVIDENCE: There have been a number of changes in management support over a number of months. This support has been forthcoming but needs to be focussed through one registered manager to prevent drift. Much information needed could not readily be found. A further service review is needed within the home. The registered provider needs to maintain monthly visits and provide feedback from staff, residents, professionals and visitors. Key policies that have been drafted need to be finalised and shared with residents. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 16 A visitors’ book was not in operation at the time of the inspection. Fire drill information was limited. There were some other health and safety matters arising such as no soap in a communal bathroom and the meter cupboard being uncovered and not secure. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 4 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 89/91 Bessborough Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score 1 x 2 2 2 1 x G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 18 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA33 Regulation 4, 5 Requirement The home must have documents entitled Statement of Purpose and Service User/Residents Guide freely available within the office. Copies must be sent to the Commission for Social Care Inspection. (Previous timescale not met). A copy of the Service User Guide must be given to each resident. (Previous timescale not met). Residents individual plans need to capture both the planned and actual methods in which each residents needs will be addressed and with respect to any updated CPA meeting decisions. (Previous timescale not met). Individual PRN (as needed) guidance is required for staff, to be clear as to the circumstances that GPs advise for each service use - to have such medication . (Previous timescale not met). The missing PRN medication from one residents box needs to be accounted for. The medication trolley needs to be secured. Timescale for action 1/4/05 2. YA1 5(2) 1/4/05 3. YA6 15(2) 1/5/05 4. YA20 13(2) 1/5/05 5. 6. YA20 YA20 13(2) 13(2) immediate notification 1/7/05 Page 19 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 7. YA20 13(2) 18(2) 8. YA23 13(6) 9. YA24 23(2) 10. YA24 23(2)(b) 11. 12. YA24 YA33 23(2)(b) 18(1)(a) 13. YA35 19 14. YA35 15. YA37 17(2) Schedule 4 Part 6(a) 18(1)(c) 10 The CSCI Pharmacy Inspectors last report was not available for inspection and it could not be addressed whether the medication policy needs to meet the policy needs and is followed. (Previous timescale not met). The new adult protection policy needs expanding to include response times. The reporting procedure needs to be accurate. (Previous timescale not met). The carpets in the corridors leading to the bathroom and in the hallways need to be replaced. (Previous timescale not met). Hallway gap to the smoking lounge which is a tripping hazard needs to be addressed. (Previous timescale not met). The wooden stair banisters must be revarnished due to wear. (Previous timescale not met). The staffing levels between 8.30 pm and 9 am must be reviewed. The registered provider must justify in writing to the CSCI as to when the agreed staffing levels of at least two staff during day hours is expected to start and finish. (Previous timescale not met). A training and development plan for the staff group needs to be implemented. (Previous timescale not met). Training profiles for agency staff must be in place. (Previous timescale not met). A permament full time home manager appointment must be made as soon as possible. A further service review is required. It must consider how 1/5/05 1/4/05 9/10/03 15/4/05 1/2/05 1/3/05 30/9/03 1/12/04 16. YA39 21, 24 1/6/05 Previous timescale not met 1/2/05 Page 20 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 17. YA39 26 18. YA40 12 19. 20. YA41 YA42 Schedule 4 23(4) 21. 22. YA42 YA42 16(2)(f) 23(2)(b) the goals from the previous review have been progressed. (Previous timescale not met). Monthly visits of the home on behalf of the registered provider must include feedback from consenting residents, staff and visitors, so as to make a judgement about the standard of care provided at the home. Reports must reflect this. The reports were not available for inspection. They must be promptly copied to the CSCI. (Previous timescales not met). Key policies that have been drafted must be finalised and shared with residents. (Previous timescale not met). A signing-in book needs to be in place to record visitors to the home. Fire drills must take place regularly based on the needs and abilities of the people involved and details captured of evacuation time. Soap dispensers need to be installed in all bathrooms. The meter cupboard in the alleyway at the side of the home needs to be covered and made secure. 15/4/05 1/2/05 1/7/05 15/3/05 1/9/05 1/8/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA28 Good Practice Recommendations A risk review should take place to ensure that the home, given its layout, is suitable for its stated purpose to safeguard the residents from possible harm. The space for sleeping over in the office is inadequate. This should be reconsidered by the involved organisations G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 21 89/91 Bessborough Road 3. YA33 in the home. It is recommended that the one vacant post be permanently recruited for by the employer. 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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 89/91 Bessborough Road G62-G11 S17519 89-91 Bessborough Road V231557 060605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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