Inspection on 05/09/05 for 93-95 Canning Road

This inspection was carried out on 5th September 2005.

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

Other inspections for this house

93-95 Canning Road 19/03/08

93-95 Canning Road 21/09/06

93-95 Canning Road 15/11/05

93-95 Canning Road 02/12/04

93-95 Canning Road 28/09/04

93-95 Canning Road 23/03/04

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Edenvale

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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 93-95 Canning Road 93-95 Canning Road Wealdstone Middlesex HA3 7SP Lead Inspector Andreas Schwarz Unannounced 5 September 2005 9.00am 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. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 93-95 Canning Road Address 93-95 Canning Road Wealdstone Middlesex HA3 7SP 020 8424 8186 020 8424 0879 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 Ross Hensman Care Home 6 Category(ies) of LD, 6 registration, with number of places 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd December 2005 Brief Description of the Service: 93-95 Canning Road is a registered care home providing personal care and accommodation for a maximum of 6 adults aged 18-65 who have learning disabilities. There were 6 service users living in the care home at the time of the inspection.The Registered provider is the Harrow Consortium for Special Needs and the Responsible Person is Mr. Robert Seaman. The Registered Manager Mr. Ross Hensman was available during the unanaounced inspection. Paddington Churches Housing Association (that takes responsibility for its maintenance) owns the building. The care agency is Harrow Mencap that employs the staff in the care home.The home is located in a quiet residential road in Wealdstone on the outskirts of central Harrow. It is close to shops, pubs, transport and other community amenities.All the home’s bedrooms are single, and none have en-suite facilities.The home has a garden to the rear that is accessible through the lounge and kitchen 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in September 2005. The registered manager Mr Ross Hensman was available throughout this inspection. The inspector spoke to two residents and one member of staff during this inspection. The inspector has assessed a number of case files and records relating to the home and residents. The registered manager showed the inspector around the home. The inspector would like to thank residents, support workers and registered manager for being so welcoming and helpful during this inspection. What the service does well: What has improved since the last inspection? The acting manager Mr Hensman has been appointed as the permanent registered manager for the home. The home will have a full and permanent staff team within the next two weeks. The home has received funding to provide day service for one service user living in the home. The home complied with the majority of requirements made since the last inspection. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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) 2 Residents’ needs are assessed to high standards, however there was no clear evidence if service users are involved within this process EVIDENCE: The inspector discussed the assessment process with the registered manager. The Head of Care Services of Harrow Consortium has assessed the most recent admission to the home for Special Needs. The assessment viewed by the inspector was clear and detailed and it was evident that information gathered form part of the residents support plan. The inspector viewed the homes assessment policy, which was robust and detailed. There was no evidence within the viewed assessment, if the new resident has been involved in the process; this is required for future assessments done by the home. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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 home has Individual Programme Plans in place and residents’ involvement is clearly evident. The home is assessing potential risk to residents and encourages service users to life an independent live. EVIDENCE: The inspector viewed two residents Individual Programme Plans (IPP), these plans are in an A3 format and available in a pictorial form. The plans viewed by the inspector have been reviewed annually and there was clear evidence, that residents are involved in the IPP process. The manager informed the inspectors that key workers meet with their key resident regularly and service users have contributed to the plan through writing, pictures or other communication tolls, which was clearly evident when viewing the IP plans. The plan records clearly, which actions have been achieved and what is still outstanding in the future. The home stores review minutes in a separate folder and clear records where available of the attendance. The inspector informed the registered manager, that he judges the IPP format as a suitable document for the residents living at Canning Road. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 10 The home has clear risk assessments and relevant procedures in place. The procedure viewed by the inspector explained in detail why and when risk assessments are necessary. The risk assessments viewed by the inspector were detailed and range from medical appointments, challenging behaviour, First Aid, domestic tasks, accessing the community, etc. The inspector however noted a lack in reviewing these risk assessments and this was with the registered manager and is required. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 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 standard(s) 13; 17 Residents have community presence and take part in opportunities offered within the local and wider community. Residents’ benefit from and choose a wholesome and well balanced diet. EVIDENCE: One resident informed the inspector of attending work; attend the local day centre, visit the pub, cinema, etc. In addition to this the resident told the inspector of going on holiday to a farm this year, he explained that he choose to go on this holiday, but he was not to happy with the food on offer. However the manager informed the inspector, that the home provided funds to go out or cook in the self-catering accommodation. Care plan files confirmed that the home offers a wide range of activities and skill training, i.e. budget braining, road crossing training, snooker, pub, cinema, etc. A second resident spoken to during this visit confirmed this. The home does not provide their own transport. The inspector assessed the weekly menu, which was judged of being appropriate, varied, whole some and healthy. Residents informed the inspector of being involved in choosing of what they want to eat and the manager 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 12 confirmed this. One resident said if he does not like some thing he could go to the fridge and cook something else. The home records menu choices made by the residents and staff told the inspector that residents help going shopping and/or cooking. The home records fridge and freezer temperature daily. The inspector viewed the fridge and freezer during this inspection and a number of food items have not been labelled after opening; this is required. The inspectors suggested of taking pictures of dishes and design a photographic menu for residents. Residents should be involved in this, in particular one service users who shows interest in photography. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 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 standard(s) 18 Residents are supported appropriately and can choose the level of support. EVIDENCE: The home is providing minimal personal care support and residents are encouraged to be as independent as possible. Residents have been observed of being encouraged having a bath and choose when they want to get up considering work or appointments. All residents have a key worker and attend regular meetings discussing their care plans and other relevant issues. The inspector observed the manager talking to families and informing them of important activities provided the residents agree to do this and give their permission of disclosure.. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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 Residents are listened to and complaints are acted upon, however one clear complaints procedure must be provided. EVIDENCE: The inspector viewed two complaints procedures one from Harrow Consortium and one from Harrow Mencap, both procedures do not clearly refer to the CSCI as an organisation which can be contacted if complaints are made and the CSCI address. Residents told the inspector that they know who to complain to and that the manager listens if they have a problem. The Harrow Mencap complaints procedure is available in pictorial form. The home has clear records of complaints received and actions taken by the manager or investigator. The inspector informed the manager of providing one complaints policy as required in previous inspections. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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 93-95 Canning Road is nicely decorated house and residents live in a comfortable and safe environment. EVIDENCE: The manager showed the inspector around the building, the inspector was not able to view resident’s rooms during this inspection. On previous inspections it was required to clean or replace the stained carpet in R’s room. The manager informed that carpets have been cleaned, but the dirt was not possible to be removed. Residents are in the process of choosing new carpets for the lounge and R’s room and carpet samples have been shown to the inspector. The grouting in the down stairs shower room has been resolved, but the floor is very worn and stained and must be cleaned or replaced. The upstairs bathrooms vent was not working and must be cleaned in addition to this, the tiles over the bathtub were missing. The manager informed the inspector of having assessed the home for repairs, but records were not available for inspection 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 16 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; 35 An effective, stable and appropriately trained staff team supports residents and consistent as well as appropriate support is provided. EVIDENCE: The inspector viewed the rota. Staff is still supporting residents at the Independent Living Scheme, but this is clearly indicated on the rota and the manager informed the inspector that this arrangement would cease from 19/09/05. There is two staff working during the morning and two staff during the evening. A new deputy manager has commenced employment and a new support worker will transfer from another home in the coming week, this means that the home has a full staff team supporting the residents. The manager informed the inspector that the additional day service hours will not been made available as a permanent post and the hours will be covered with regular bank workers, this will allow the manager of being more flexible when sickness or training days must to be covered. The inspector viewed training records and it is evident that staffs attend a wide range of compulsory and specialist training. Training applications have been seen displayed on the notice board in the office. Previous inspections raised the lack of compulsory training, which was found to be complied with. Staff does not have a training and development plan, this was discussed with the registered manager 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 17 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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) 39; 42 Residents have a say in how the service should be run, however the home does not have an annual development plan. Appropriate policies and procedures protect the Health and Safety of residents. EVIDENCE: The manager informed the inspector that he is currently in the process of writing an annual development plan for the service; a draft copy has been viewed on the computer. The inspector informed the manager, that this plan must be discussed in residents-meetings, staff-meetings and with families for contributions, to get a holistic picture of what should be implemented or changed in the future. Once completed the registered manager must forward a copy of the Annual Development Plan to the Lead Inspector of the home. A number of Health and Safety certificates such as gas and portable appliances test certificates have been viewed by the inspector, all of them have been up to date. The inspector could not find an Electrical Installations certificates, 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 19 which is required. An Annual check of the home’s water system for Legionella is still outstanding. Fire records such as three monthly drills, fire alarm test, fire risk assessment and fire point test have been viewed and all of them were of good standard. A number of staff has not received any fire training, the inspector explained that this is required and all staff must receive training in fire safety. Policies and procedures regarding Health and Safety have been viewed and all were judged as being of good standard. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 20 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 x 2 x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 x x x 2 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 93-95 Canning Road Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 21 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. 2. 3. 4. Standard YA2 YA9 YA17 YA20 Regulation 14(1)(c) 13(4)(b) (c) 13(4)(c) 13(2) Requirement New prospective residents must be involved in the assessment process. The registered manager must review all risk assessments. Food must be labelled and dated after opening when stored in fridge. It is required that the six requirements arising from the Commission for Social Care Inspection Pharmacist Inspectors report are complied with, within the stated timescales. There must be a clear ‘Complaint Procedure’ for the Registered Person to consider complaints (made by a service user or person acting on the service users’ behalf) about the care home. This must include details on how to contact the Commission for Social Care Inspection local office. (Expired 02/03/05) The first floor bathroom ventaxia requires repair as was not working and also cleaning. (Expired 02/03/05) The stained carpet in Rs room Timescale for action 30/09/05 30/09/05 ongoing 15/09/05 As stated 5. YA22 22 31/10/05 6. YA24 23(2)(d) (p) 23(2)(d) 30/09/05 7. YA24 31/10/05 Page 22 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 must be replaced. 8. YA24 23(2)(c) Arrange for bedrooms within the care home to be assessed with any broken items of furniture/fittings/fixtures (including water pressures) repaired or replaced. Copy of assessment to be send to the inspector (Expired 02/03/05) The dirty floor in the GF shower room must be cleaned or replaced Missing tiles in the upstairs bathroom must be replaced All staff must have a training and development plan reviewed anually. The annual review of the quality of care and support within 93-95 CR must be undertaken with a copy of the report forwarded to the Commission for Social Care Inspection.(Timescale of 23/8/04 & 01/04/05 not met) An annual check of the hot water systems within the care home must be carried out in order to ensure the control of the risk of Legionella. (Expired 02/04/05) The registered manager must provide a valid Electrical Instalation Test certificate All staff must receive appropriate fire training on an anual basis. 30/09/05 9. 10. 11. 12. YA24 YA24 YA35 YA39 23(2)(d) 23(2)(d) 18(1)(a) 24 31/10/05 30/09/05 30/09/05 31/10/05 13. YA42 13(4)(c) 31/10/05 14. 15. YA42 YA42 13(4) 23(4)(d) 30/09/05 31/10/05 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. Refer to Standard YA17 Good Practice Recommendations The inspector suggets taking pictures of dishes and design a pictorial menu. 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 4th 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 93-95 Canning Road G62-G11 S17522 93-95 Canning RD v212195 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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