Inspection on 11/10/05 for Alison House

This inspection was carried out on 11th October 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 23 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Alison House 23/07/07

Alison House 23/01/07

Alison House 20/06/06

Alison House 15/03/06

Alison House 09/02/05

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 Alison House 16a Croxley Road London W9 3HL Lead Inspector Ann Gavin Unannounced Inspection 11th October 2005 14:00 Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Alison House Address 16a Croxley Road London W9 3HL 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) 020 8960 0990 Westminster Primary Care Trust Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Bedroom A6, which measures 8.7 square meters, must not be used to accommodate service users who are wheelchair users. Long Stay for One Resident: To extend the stay of one resident until suitable accommodation is found. The variation takes effect from 1st April to 31 October 2005. 9th February 2005 Date of last inspection Brief Description of the Service: Alison House is a care home for up to six clients, of either gender, with learning disabilities providing short-term and respite care. There are currently thirty clients that have been assessed to receive respite care. There is one bed allocated for an emergency placement. It is operated by the Westminster Primary Care Trust, who lease the building from the Westminster Society for people with disabilities and was registered on 7th December 2004. The facility is located in the Maida Vale area and is within easy access of local shops, other amenities and transport links. It provides ground floor accommodation and there are six single bedrooms available. A condition of registration is that one bedroom that measures 8.7 square metres is not allocated to a wheelchair user. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection from 2pm until 5.30 pm. There was a team leader and two support workers on duty. One service user was in the home and one other service user came for a short evening break. Out of the eleven requirements made at the last inspection ten of these had not been met. Three immediate requirements were made 1. Requesting an action plan with timescales for each of the requirements. 2.To make sure that fire drill and equipment checks are carried out. 3. To request details of how the home are working to ensure that a permant manager is in place. The home was generally shabby and lacking in the comfortable homely environment expected by the care standards. The staff on duty did not demonstrate an awareness of the policies and procedures of the unit. A further ten requirements were made. Following the inspection a meeting was arranged with the responsible individual where an action plan was produced and new timescales agreed. 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. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 staff on duty were not able to show any written plans for the young people in the midst of the transition process from children to adult services. The assessment of service users needs have been assessed by the care manager but not by the service. Alison House need to have written transition plans and their own assessments of all prospective referrals. EVIDENCE: One of the team leaders went through the way the transition from children to adult services and the referrals to Alison house are carried out. This is carried out with meetings with the service user and families either at their college or home. Subsequent visits to the home with stays for lunch or dinner building up contact until an overnight stay is planned. This process the team leader explained can take from between one to six months. However none of this process, the team leader said, was in a written plan. A written plan needs to be in place to ensure all parties are aware of the transition process. Some of the referrals seen from Care Managers had been signed although none of the part required by Alison House staff had been completed. Alison House need to complete their part of the assessment to ensure that they can meet the needs of the service users referred to them Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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): 6,9 Care Plans still need to be updated and risk assessments completed for each service user. They also need to be reviewed regularly. These were all requirements form the last report. EVIDENCE: The care plans seen had not been updated and lacked a real sense of the total needs of the service user. The care plans need to describe all aspects of service users personal care, their preferences in social and leisure activities all the aspects set out in standard 6 of the care standards. The whole emphasis has to be to be more focused on the service users needs and preferences. A profile of each service user needs to be in place to ensure all staff are aware of the care required for each service user. These need to be reviewed regularly as stated in the requirement from the previous report. The requirement to make sure that all service users have a risk assessment which is updated every six months still needs to be completed. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 9 The daily contact sheets need to give a flavour of the type of day the service user may have had, the activities, contact with friends families etc. Those seen varied in quality and information. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 the following standard(s): These standards were not assessed at this inspection. EVIDENCE: Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 the following standard(s): 18,20 Alison House has nurses as part of the staff group. The medication records seen still had the same issue as of the last inspection, blanks without explanations. The personal needs of service users must be carried out discreetly without personal information placed on the wall and incontinence pads displayed on wardrobes. EVIDENCE: The team leader explained that the nursing staff use their skills around healthcare issues such as peg feeding, catheterisation medication and behaviour. The clarity of the staff roles within the home and within the spirit of the care standards act still needs to be completed by the providers. The personal care needs of one service user was seen displayed on the wall beside the bed they were using up until the day before the inspection. Personal information should not be displayed in rooms both for the dignity of the person and the confidentiality aspect. This information should form part of a persons care plan. For complex procedures information can be kept on a separate sheet but within the care plan and replaced once the instructions are followed. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 12 The practise of storing a supply of incontinence pads and towels on top of service users wardrobes is unnecessary given that the cupboard is just outside the doors of the bedrooms. This practise does not enhance the service users dignity. A requirement of the previous report was to make sure that medication records are kept up to date with no blanks in the recording. Looking at the medication records showed that blanks still occur with no reason given. On discussing with staff it seemed that most blanks referred to times when service users were not in the home. However staff must make sure that reasons are given for any gaps in medication. The acting manager and service manager must carry out the spot check medication audits as stated in their response to the last inspection report. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 13 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): 22,23 All staff on duty need to be aware of the homes complaint policy how to accept and record a complaint. The home must develop a service specific adult protection policy. EVIDENCE: The staff on duty were not aware of the complaints procedure nor where to find the complaints book. Any complaints would, they said, be passed to the acting manager verbally for them to deal with. The staff did know of complaints but neither of outcomes nor where to find the information. All staff must be aware of and adhere to the complaints policy to ensure that service users and their families can make complaints and be assured of a consistent approach to being heard and any issues dealt with. The staff were aware of the joint adult protection procedures produced by Westminster and Kensington and Chelsea. The staff have been working on a policy specific to Alison House this needs to be completed. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 14 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): 24,30 Alison house need to work hard to ensure that service users are cared for in a homely, comfortable and well maintained environment. The home is shabby, institutional and in need of complete redecoration. A homely environment needs to be created and planned regular maintenance to be scheduled. NHS logo linen and bedcovers need to be replaced with more appropriate bed linen for service users. EVIDENCE: There were a number of requirements made at the last inspection concerning the environment. The provider must ensure that timescales are provided for all the works requested. One bedroom is still used as a staff sleepover when there are less than 6 service users. With full occupancy there are two waking staff on duty. The shower in the room was used for storage and it remains without a wardrobe. The home must follow the agreed staffing level at registration and not vary the ratio based on occupancy. If the home wish to change a variation application to reduce numbers to five must be made to provide a staff sleep in room. Each of the bedrooms had beds which were made with NHS linen and blankets with the NHS logo emblazoned on the sheets pillowcases and blankets which led to a clinical appearance to the bedrooms. These need to be replaced with Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 15 more appropriate linen. The home use a laundry service as the laundry room is very small and there is inadequate ventilation for the machines in use. There is a sign which states that no service users clothing is to be washed in the laundry. The whole home needs redecoration and the provider must provide timescales for this. The bathrooms could benefit from some personalising decoration. A toilet in the shower room had a seat without any lid this must be replaced. The damp needs to be addressed and dealt with in the bathroom and the bedrooms. It is recognised that the home has little space and storage of large items such as shower trolleys remain a difficulty. The home was clean and fresh smelling. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 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 The staff on duty did not show an awareness of the units overall policies and procedures in relation to the care standards act. This must be addressed by training and cohesive policies for the unit. EVIDENCE: The staff,when asked about policies and procedures, were aware of the PCT policies but showed no recognition of any policy in relation to the care standards act. They appeared unaware of the regulation 37 form, the need to notify the commission about any incidents, accidents or any adverse events which effect service users. There needs to be comprehensive and coherent policies for the unit with training to ensure that all staff are aware of the polices and procedures they are working to. The staff said that they only have two waking staff when there are six service users in the unit. Otherwise there are one waking and one sleep in staff each night. The staff said that if there were planned activities for the service users extra staff are on duty. There are regular staff meetings which staff said was policy rather than service user focused. There is a keyworking system which has just recently been updated. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 17 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): 37,42 Alison House has an acting manager. There is a need to secure a permanent manager. There were no recorded fire drills or checks of safety equipment written. The staff need to make sure that the front door of Alison house is kept secure at all times. EVIDENCE: On arriving at the unit the front door was found open the staff on duty said this was due to the cleaner being on duty. This door needs to be secure at all times. The acting manager was not on duty at the time of the inspection but staff said there had been two managers since last year. An immediate requirement was made to request plans that the providers had to recruit a permanent manager. The staff were unsure where the log books for the fire drills and alarm checks were those that they did bring had nothing recently recorded. These must be Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 18 done. Equally the equipment checks must be carried out regularly. The fridge and freezer checks had been done. There were assessments for COSSH products which were kept all together in the office. The system was not very accessible and it was not clear if all products had an assessment and how they were updated. These should be kept near the products in the kitchen in a clear format with a system to ensure they are regularly updated. Alison House DS0000055306.V257867.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X X x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Alison House Score 2 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000055306.V257867.R01.S.doc Version 5.0 Page 20 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 Standard YA2 YA2 Regulation 12 &14 15 Requirement Referrals made to the home, by the panel, must be dated and signed. Repeat Requirement Staff must have a written transition care plan and complete their own assessment of each service user referred to the unit. All clients care plans must be updated and regular reviews attended by the relevant placing authority representatives must take place. Repeat Requirement All clients receiving a service must be risk assessed with six monthly reviews taking place. Repeat Requirement The organisation must clarify with the CSCI the role of staff within the home, whom hold a nursing qualification, but are not employed as such as the home is not registered to provide nursing care. Repeat Requirement Staff must remove all incontinence pads displayed on wardrobes in service users rooms. Staff must ensure that all DS0000055306.V257867.R01.S.doc Timescale for action 31/12/05 31/12/05 3 YA6 15 31/12/05 4 YA9 13,14 31/12/05 5 YA18 17 & 18 31/12/05 6 YA18 12 31/10/05 7 YA18 12 31/10/05 Page 21 Alison House Version 5.0 8 YA20 13 9 YA22 22 10 11 YA23 YA24 13 23 12 YA24 16 13 14 YA27 YA30 23 23 personal care details are not displayed on the walls of service users rooms The medication administration records must be kept up to date with no blanks in the recording. Repeat Requirement All staff must be aware of and work to the home complaints procedure. A written record must be kept of all complaints. The home must conclude their service specific policy on adult protection The provider must make sure that the whole environment is redecorated and provide the commission for timescales for completion The home must change the laundry currently used at the home with the NHS logo on all sheets and pillowcases to provide a more sensitive and personal bedding The toilet in the shower room must have a properly fitted seat and lid. The laundry room must be adequately ventilated for the machines in use. Repeat Requirement The alternative emergency exit, through bedroom six, must be re-assessed to make sure it is accessible for wheelchair users to be assisted to leave the building that way. If it is not a suitable alternative must be found or work carried out to make it accessible. The kitchen worktops must be made height adjustable so that clients in wheelchairs can use them if they wish. Repeat Requirement 31/10/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 31/12/05 15 YA24 23 31/12/05 Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 22 16 YA24 23 17 YA24 18 18 YA37 8 19 YA39 26 20 YA43 23 21 22 YA42 YA39 23 44 23 YA42 23 Bedrooms three, four, five and six must be redecorated and a wardrobe provided in bedroom three. The TV wall brackets in bedrooms five and six must be resited so they can be used. A curtain rail that works must be fitted and curtains of suitable length supplied. The carpet in bedroom six must be replaced. The heating thermostat must be resited so that bedroom six is adequately heated Repeat Requirement The home must follow the agreed staffing level at registration and not vary the ratio based on occupancy or a variation application to reduce numbers to five clients must be made to provide a staff sleep in room The providers must inform the commission of their plans to appoint a permanent manager Immediate Requirement Unannounced monthly person in control visits must take place and a report sent to the local CSCI office. Repeat Requirement The home must seek clarification from the LFCDA regarding appropriate siting of the fire panel Repeat Requirement There must be regular fire drills and equipment checks Immediate Requirement An action plan for timescales must be provided to the commission for all the outstanding requirements from the last inspection. Immediate Requirement COSSH assessments must be completed on all products and an accessible and updated system kept close to the products. DS0000055306.V257867.R01.S.doc 31/12/05 31/12/05 31/12/05 31/10/05 31/12/05 31/10/05 21/10/05 31/12/05 Alison House Version 5.0 Page 23 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 Alison House DS0000055306.V257867.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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