Inspection on 25/05/05 for Becklow Road

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Becklow Road 08/02/08

Becklow Road 13/11/06

Becklow Road 24/05/06

Becklow Road 01/07/04

Becklow Road 05/06/04

Becklow Road 07/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 BECKLOW ROAD, 161/163 161/163 Becklow Road Shepherds Bush LONDON W12 9HH Lead Inspector Jackie Derbyshire Announced 25 May 2005 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. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Becklow Road, 161/163 Address 161/163 Becklow Road, Shepherds Bush, LondonW12 9HH 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) 020 8932 3916 020 8743 2333 Yarrow Housing Ltd Mr Michael Antonio Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd December 2004 Brief Description of the Service: 161/163 Becklow Road is a detached home for 6 people with a Learning Disability. The home is registered for adults age 18-65. There are 5 service users living at Becklow Rd at present. The home is operated by Yarrow Housing Limited, and is located in the Shepherds Bush area of London. The house comprises of a three storey modern building - the top floor providing an office, shower and w.c, also sleep-in facilities for staff. The 1st floor has three bedrooms, lounge, kitchen and bathroom/toilet. The ground floor has three bedrooms, kitchen, lounge and two specialist bathroom/shower rooms. The lounge leads onto a garden/patio area. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on 25th May 2005. The inspection took 6 hours. The Manager was absent the Deputy Manager assisted the inspector with all of the information required. The inspector spent time talking to service users and staff, touring the building, checking records and documentation. Two service users files were checked for all relevant information. 5 of the 9 requirements set December 04 have been met, there are 4 new requirements. What the service does well: What has improved since the last inspection? The home has improved the financial procedure and all service users monies checked was correct with the receipts in place for any purchases. Service user questionnaires were seen to be in place and are used as part of the homes annual quality assurance monitoring. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 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. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 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 BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 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 and 5 The home has all relevant documents in place for prospective service users. EVIDENCE: The 5 service users living at the home have lived there for many years. The home has got the relevant information in place for prospective service users in the form of a Statement of purpose and service user guide. Yarrow has a thorough policy on new admissions to their homes. 2 service user files were looked at by the inspector and both had a contract one that had been signed and dated and agreed by both the service user and the Manager, the other had not been signed by either person. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 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) 6,7 and 9 Care plans have not been updated and records for reviews are out of date. EVIDENCE: Two service user files were looked at and both had care plans in place called Person Centred Planning (PCP). These plans are put in place with the service user whose input is sought throughout the process; this ensures the care plan is what the service user requires from the home. Both PCP’s were out of date. The inspector spoke with all 5 service users 3 of which are not able to communicate very well. The two service user that could communicate stated they were happy with the assistance they receive and were very happy living at Becklow Road. The organisation’s risk management systems are well implemented; risk assessments were seen to be up to date on all service users. The assessments included general health and safety issues and risk factors for each service user. The assessments covered daily life in the home and in the local community. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 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) 12,13,15,16 and 17 Links with the community are good and support to enrich service users social and educational opportunities. EVIDENCE: All of the service users have a full activity plan that was written in their files and also on the notice boards in each kitchen. A varied weekly plan including visits to Yarrow’s day service, The Gate, the Macbeth centre and visiting the shops on outings with staff from the home. One service users activity plan is being looked at for more varied activities, an activity coordinator from The Gate is liaising with the Deputy Manager. Four of the service users went on a day trip to Southend on the day of the inspection, the Deputy manager stated that they try to have weekly outings for all the service users to go together as they have access to a minibus. One service user has their own car and is taken out as much as is practicable. Visitors are welcome at Becklow house, some family choose to telephone rather than visit. Meal times are generally flexible to fit in with activities and individual choices. There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced. Menus were on the notice board of each kitchen. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 11 BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 standard(s) 18,19,20 and 21 The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Personal support is provided in the privacy of the service users room or in the bathroom. Two of the service users are semi- independent and complete their own personal care needs with minimal staff assistance. Three service users require full assistance in all care needs. All of the service users have a local GP and are supported to attend appointments. Records looked at for two service users showed that optician, dental and GP visits have been recorded. The Inspector checked the medication administration records for five people living in the home. Overall, the Inspector felt that the standard of medication recording was very good. Secure storage was provided for all prescribed medication in a lockable metal cupboard in the kitchen on both floors. Two service user files checked by the inspector had a plan of their wishes in the event of death. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 standard(s) 22 and 23 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. Service users finances were well managed and accurate records were kept. The finance records for all of the service users were checked. Each contained a record of all income and expenditure. Receipts were obtained for all transactions and the records were regularly balanced and checked by the Deputy Manager. The complaints records were checked and there has been 1 complaint in the last 12 months, this complaint is from a neighbour who is very concerned about the noise levels at night form one of the service users. An immediate requirement was made as the intercom system in the home is broken and staff do not know who they are opening the door too. This in effect can mean that the service users are not being protected as strangers can be given access. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 standard(s) 24,27,28 and 30 The standard of décor within this home is poor with little evidence of improvement through maintenance or future planning. The home does not therefore present a homely and comfortable environment for service users. EVIDENCE: The inspector had a full tour of the house and all communal rooms were seen. All 5 service users bedrooms were also seen. There is a desperate need in Becklow Road to decorate all areas including the bathrooms. In discussion with the Deputy Manager it was stated that the house was waiting for the service users to go on holiday before they decorated. The decoration of the home and new carpets throughout had been set as requirements on the last 3 inspections. The Deputy Manager has been notified that the home has to be seen to be adequately decorated by August 2005. The home was clean and tidy, service users stated they assist to keep their rooms tidy. The home is not accessible to people with limited mobility there is no lift to access the top floor, this will eventually become an issue for all people living in the home. The only equipment at present is a handrail in the each bathroom. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 15 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) 31,32,34,35 and 36 The recruitment procedure in the home is good with good arrangements for the induction of staff. Staff showed a good knowledge of their roles and responsibilities. EVIDENCE: The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff have up to date checks completed. The Deputy Manager confirmed that all new staff complete the care services induction programme developed by the Learning Disability Awards Framework (LDAF). There are 4 full time vacancies and 1 part time at present these vacancies are filled by Bank staff from Yarrow. All staff have job descriptions and have clearly defined roles and areas of responsibility outlined. The Deputy Manager confirmed that Yarrow had a programme of National Vocational Qualification training for all staff in the organisation. Two of the staff have NVQ level 2 and three are working towards level 2. One of the team has level 3. The Deputy Manager has completed the RMA (Registered Managers Award). The staff rota was looked at and discussed. All staff spoken with stated they were happy with the training they had completed and that Yarrow provided all of the training they required. Staff records were BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 16 checked and all staff have regular supervision, there is a requirement that all staff receive annual appraisals as this is not happening at Becklow Road. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 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 and 42 The Manager is supported well by the Deputy Managers in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The inspector felt that the home was very open and friendly, staff and service users were working very closely. There is a need for the PCP meetings and reviews to be completed on a regular basis as is written in the homes Statement of purpose. An annual business development plan is produced, which includes reviews of policies, aims and service user/staff development, there is a requirement this document be sent to the CSCI. Service users questionnaires are provided by the home and are completed by the service users, these are completed as part of the PCP meetings. The inspector saw questionnaires completed by service users. In discussions with the service users they did not raise any issues and stated they were happy living at Becklow Road. Records were checked for the fire alarm and fire drills, all other BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 18 records ensuring the health, safety and welfare of service users were checked. The Inspector found the Manager and staff helpful, professional and knowledgable. BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 3 x x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 BECKLOW ROAD, 161/163 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 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 YA5 YA6 Regulation 5 15 Requirement All tenancy agreements to be signed and dated by service users and the Manager. Care plan reviews to be completed at the stated time as written in the homes statement of Purpose. The intercom on both floors to be repaired. This is an immediate requirement. The ground floor bathroom to be redecorated and tiles replaced on walls. This is a repeat requirement. All staff to have annual appraisals. Monthly PIC visits to take place by Yarrow and copies of the reports to be sent to the CSCI. This is a repeast requirement. An annual quality assurance report to be sent to the CSCSI. All communal areas to be decorated and new carpets to be provided.This is a repeat requirement. Timescale for action 30/06/05 31/07/05 3. 4. YA23 YA27 12 23 27/05/05 August 2005 31/08/05 31/07/05 5. 6. YA36 YA39 18 12 7. 8. YA39 YA42 12 23 End of year for Yarrow. August 2005 BECKLOW ROAD, 161/163 G60 - G09 S19147 BECKLOW ROAD AIV219922 250505 STAGE 4.doc Version 1.30 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA28 Good Practice Recommendations The portable air conditioning units to be stored away from lounge and kitchen areas as they are large and take up a lot of space. 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