Inspection on 15/03/06 for Alison House

This inspection was carried out on 15th March 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 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 11/10/05

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 15th March 2006 09:30 Alison House DS0000055306.V285219.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 Alison House DS0000055306.V285219.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. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 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.V285219.R01.S.doc Version 5.1 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. 11th October 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.V285219.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection from 10.30 am to 1.30 pm. There were no service users in the home and one long term agency staff on duty. The manager was at meetings. It was not possible to clarify all the previous requirements, as the member of staff was unaware of where the information was held. There were serious concerns over the storage and administration of medication. Unmarked medication and also out of date medication for two service users was found. Medication for a service user who had left were still there some of which was out of date others were left in an envelope stating that it was out of date but did not state what it contained or how much. There were still unexplained gaps in the recording sheets an immediate requirement notice was left. There were twenty one requirements made. What the service does well: What has improved since the last inspection? What they could do better: There is an urgent need to address the serious concerns about the storage and recording of medication. The providers must vary their registration to a care home with nursing for five adults. The provider must make sure that the requirements are met and provide a timescale for action. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 Page 6 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.V285219.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 Alison House DS0000055306.V285219.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): These standards were not covered at this inspection EVIDENCE: Alison House DS0000055306.V285219.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): 7 There is no consistency in the care plans seen and therefore it was difficult to assess this standard fully. EVIDENCE: One of the three care plans seen had a brief profile of the service user on the front, which highlighted what assistance they wished. The other two had no profile and one no current care plan. With the information made available it was not possible to see how this standard was being put into practise. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 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): 12,13,15,16,17 Alison house must make sure that care plans show a complete picture of the service users day, their choices, including all activities. The records kept must be informative and descriptive. EVIDENCE: Alison House has a monitoring of activities file. This listed the name of the service user, the staff member, type of activity, whether it was carried out and comments of the activity. This had been completed but, on the pages seen, with the exception of two staff members, the activities were put as ‘outing’ ‘shops’ ‘sensory stimulation’ but no explanation as to what or where people went and the comments were always the same ‘enjoyed it’ On two occasions the same staff member was due to take service users to the pub but this did not happen yet no explanation was made. Two staff members were consistently descriptive of the activities undertaken with service users and had meaningful comments. Though generally the recording was poor, lacked appropriate information with repetitive use of the same phrase for each service user. The daily notes seen also contained sparse information. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 Page 11 There is a record of food kept and a general shopping list which staff adapt each week. The meal monitoring form speaks of the choice service users have but does not tell you what service users chose to have. The care plans seen do not give a clear picture of the service users choice, rights or sufficient information to assess these standards. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 Page 12 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 Alison House has nurses as part of the staff group. The medication administration and storage cause serious concern. It has been a requirement of the last two inspections. The previous requirements to ensure that all gaps in recording of medication administered are explained remains unmet. The medication administration and storage needs to be urgently reviewed .The dignity of service users must be maintained at all times. EVIDENCE: The medication records and cupboard were looked at and a number of serious concerns were found. An immediate requirement was made for the following. • The medication records continue to have gaps with no explanations given • The bottles of opened medication had no dates of when they were opened • There were unmarked and loose packets of medication • • Medication for two service users that had gone beyond the expiry date. There were 5 different medications for a service user who has left the care home some of which were out of date. One envelope stated the service users initials and ‘expired medication’ but did not specify what or how much. DS0000055306.V285219.R01.S.doc Version 5.1 Page 13 Alison House • The out of date and returns medication book had not been completed since March 2005 On discussing with the agency staff about the gaps in the recoding of medication it seemed that most blanks referred to times when service users were not in the home. However this was the reason on the last inspection and suggestions and requirements were made then. Staff must make sure that any blanks in the medication records are accounted for. The new medication card allows for this with codes but they are clearly not being followed. The manager and service manager must carry out the spot check medication audits as stated in their response to the last two inspection reports. In one of the rooms there were incontinence pads left on the wardrobe the explanation given that it was easier for the staff to access. Alison House is a small 5 bedded home with everything on one floor and so easy access for all cupboards. This is a repeat requirement to make sure that the dignity of service users is maintained at all times. Alison House DS0000055306.V285219.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): 22,23 All staff on duty need to be aware of the homes complaint policy, how to accept and record a complaint. This is a repeat requirement from the last inspection. The home must send to the Commission a copy of their service specific policy on adult protection EVIDENCE: The staff member on duty was unaware of the homes complaint policy. They later found the policy in an information rack in the entrance. No record of complaints was found. That all staff should be made aware of what to do in the event of a complaint was a requirement of the last inspection. The manager needs to advise the Commission how they plan to address this. Another requirement from the last inspection was that Alison House completed their service specific policy on adult protection. A copy of the service specific policy on adult protection must be sent to the Commission. Alison House DS0000055306.V285219.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): 24 Alison House has put in new laminate flooring in all rooms. The timescale for the decoration of the entire home must be sent to the Commission. The practise of putting two bedside tables on top of each other to use as a TV stand must cease. EVIDENCE: Alison House has removed the NHS logo bed linen and replaced with attractive duvet covers. The floors have been changed. The whole home is in need of redecoration and the Commission still awaits a timescale for completion. The bathrooms remain stark with no personalised items or decoration The corridor is dominated by large comfortable chairs and a shower trolley. In one of the bedrooms the staff member had a near miss when a TV that was balanced on two bedside lockers slid whilst they were leaning across to reach something in the wardrobe. This practise of improper and unsafe use of furniture must cease. The right equipment for the TV to be watched should be purchased and risk assessments of the environment carried out. The home was clean. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 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): 34,35 The standard of record keeping and care plans would suggest that not all staff are fully trained in requirements set out in the national minimum standards. EVIDENCE: With no permanent member of staff on in the unit at the time of the inspection it was not possible to hear about staff training. The person on duty was a long term agency staff who has worked regularly in the unit for a number of years. They have attended some training and their CRB is renewed yearly. This staff member assisted the inspector with a helpful manner. Shift plans were in place though they varied in the level and detail of information. The general standard of the care and medication records seen were not of a standard expected from a trained staff team. There were two members of staff whose records were well presented detailed and service user focused. Westminster Primary Care Trust are responsible for all recruitment. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 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): 39, 42 Alison House has appointed a manager who needs to apply for registration with the Commission. There have been no monthly unannounced visits recorded by the provider. Weekly fire points checks need to be completed. EVIDENCE: Since the last inspection Alison House now only accepts the maximum of five service users. The need to apply for a variation in registration to reduce the numbers from 6 to 5 service users and to register as a care home with nursing is now well overdue. An immediate requirement was made to ensure that an application is made by the 24th March 2006. Alison House has a new manager who has been in post since the beginning of the year. The provider must make sure that they notify the Commission of any manager appointments and that the manager applies to be registered with the Commission. Alison House DS0000055306.V285219.R01.S.doc Version 5.1 Page 18 The requirement for the provider to make sure that monthly unannounced visits are made to Alison House and that a copy of the report is forwarded to the Commission has not been carried out. There is a need to make sure these visits are carried out urgently. The fire drills have been carried out and recorded as the check on equipment. However an immediate requirement was left to make sure that the weekly fire points were completed. Alison House DS0000055306.V285219.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 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 X ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 2 1 X 2 X 1 X X 2 X Alison House DS0000055306.V285219.R01.S.doc Version 5.1 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. Standard YA1 Regulation 3(4) Requirement The organisation must apply to be registered as a home providing nursing care and for a variation in numbers from 6 to 5 beds as agreed in December 2005. Immediate requirement Staff must make sure that service users decision making about their care is recorded Staff must make sure that all records kept recording service users choice, activities are specific to the service user and descriptive. Staff must have a written transition care plan and complete their own assessment of each service user referred to the unit. Repeat Requirement All clients care plans must be updated and regular reviews attended by the relevant placing authority representatives must take place. Repeat Requirement Repeat Requirement Staff must remove all incontinence pads displayed DS0000055306.V285219.R01.S.doc Timescale for action 24/03/06 2 3. YA7 14 30/04/06 30/04/06 YA16YA13YA12 16 4. YA2 15 30/04/06 5. YA6 15 30/04/06 6. YA18 12 31/03/06 Alison House Version 5.1 Page 21 7 YA20 13 on wardrobes in service users rooms. Repeat requirement The medication administration 17/03/06 records must be kept up to date with no blanks in the recording. Repeat Requirement All bottles of opened medication must have dates of when they were opened 17/03/06 8 YA20 13 9 YA20 13 10 YA20 13 All expired medication must 17/03/06 be removed, recorded and returned to the pharmacy. All medication must be properly recorded and labelled with the type, amount and, the service users name. The medications for a service 17/03/06 user who has left the care home must be disposed of correctly. No medication must be left loose or unmarked. 17/03/06 11 YA20 13 12 YA22 22 13 YA23 13 All staff must be aware of and 30/04/06 work to the home complaints procedure. A written record must be kept of all complaints. Repeat Requirement The home must send the 30/04/06 commission a copy of their service specific policy on adult protection The provider must provide the commission a timescales for when the whole of Alison House is redecorated Bedside cabinets must not be stacked up on top of each DS0000055306.V285219.R01.S.doc 14 YA24 23 30/04/06 15 YA24 13 31/03/06 Alison House Version 5.1 Page 22 other in order for the TV to be watched in a service users bedroom 16 YA24 23 The provider must give a plan with timescales to meet these two outstanding requirements. 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. 17 YA30 23 The provider must give the commission a timescale of the work to ensure that the laundry room must be adequately ventilated for the machines in use. The Manager must complete an application for registration with the commission Unannounced monthly person in control visits must take place and a report sent to the local CSCI office. Repeat Requirement COSSH assessments must be completed on all products and an accessible and updated system kept close to the products. Repeat requirement The manager must make sure that weekly fire point checks are completed Immediate requirement DS0000055306.V285219.R01.S.doc 30/04/06 30/04/06 18 19 YA37 YA39 8 26 30/04/06 30/04/06 20 YA42 23 30/04/06 21 YA43 23 15/03/06 Alison House Version 5.1 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.V285219.R01.S.doc Version 5.1 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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