Inspection on 08/02/08 for Becklow Road

This inspection was carried out on 8th February 2008.

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

Other inspections for this house

Becklow Road 13/11/06

Becklow Road 24/05/06

Becklow Road 25/05/05

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 26/03/2009.

CARE HOME ADULTS 18-65 Becklow Road Becklow Road 161-163 Becklow Road Shepherds Bush London W12 9HH Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 8th February 2008 09:00 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Becklow Road Address Becklow Road 161-163 Becklow Road Shepherds Bush London W12 9HH 020 8932 3916 020 8743 2333 info@yarrowhousing.org.uk 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) Yarrow Housing Mr Michael Antonio Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th November 2006 Brief Description of the Service: 161/163 Becklow Road is a home for 6 people with a learning disability aged 18 - 65. There are 6 people living at Becklow Rd at present, four men and two women. The home is operated by Yarrow Housing Limited, and is located in the Shepherds Bush area of London. The house is a detached, three storey modern building - the top floor providing an office, shower, toilet and 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 accessible bathroom / shower rooms. The lounge leads onto a large garden/patio area. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience a good quality service. This unannounced key inspection took place on Friday 8th February 2008 from 08:45 – 12:30. The Inspector spent time talking with residents, staff and the Registered Manager, checking care records and touring the building. The Inspector also reviewed the care of two people living in the home in more detail. The home provides an adequate standard of accommodation, remedial works needs to be completed throughout the home, and furniture in some areas needs replacing or repairing. The home is well staffed to meet the care needs of all of the people living there at this present time. People living in the home are supported to take part is a varied programme of activities during the day, evenings and at weekends. The 3 requirements made at the last inspection have all been met. Relatives and health and social care professionals returned three confidential surveys and their comments are included in the report. The Inspector will also refer to the Annual Quality Assurance Assessment (AQQA) that was sent to the CSCI 12/10/07. The weekly fee for the service is £1,575. What the service does well: The staff are now fully trained and aware of Person Centred Planning (PCP) assisting all residents to participate and use the relevant communication skills that encourage reviews to be an important but enjoyable process. The Inspector saw information including lots of photographs and pictures that the residents had participated in as part of their (PCP) reviews. The home is well staffed to meet residents care needs and staff supported three of the six residents to take part in activities in the local community during this inspection. Standards of care planning are good and there is evidence that residents are involved in writing their care plans whenever possible. Staff working in the home have a good understanding of anti discriminatory practice and the make up of the staff team reflects the diverse group of the residents living in the home. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home only take place if the service is confident staff have the skills and ability to meet the needs of the prospective resident. EVIDENCE: Information provided by the Manager before this inspection in the AQQA confirmed that a new resident has moved into the home since the last inspection. The Inspector looked at the local authority assessment information for this resident and the Manager had completed the home’s assessment to make sure that the staff could provide the care needs required. All of the relevant documents were then seen to be in place including a care plan and risk assessments. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plan is a working document reviewed regularly involving the person and their representatives, as appropriate. EVIDENCE: Comment from health professional: ‘All of the staff really work hard to provide a good service to all of the people who use the service’ During this visit the Inspector checked the Person Centred Plans (PCP) of two people living in the home. The two files checked during this visit were both well organised and up to date. The staff and residents are using a video camera as part of the PCP’s and all residents’ files had a DVD that is updated at regular intervals and used at reviews. Both files included the Service User Guide, PCP Planning Book and Action Plan review. The Action Plans included clear goals for individuals and details on how these would be met by staff in the home and others. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 10 Both files included a weekly programme of activities for the individual residents. Surveys sent to the CSCI said that the residents are happy with the activities provided and reflect residents’ choices and preferences each day. During this visit, three of the six residents took part in activities in the local community, supported by care staff. Surveys returned to the CSCI stated that residents were happy with the activities provided. Both files checked during this visit included updated risk assessments covering challenging behaviours, travel by car and public transport and details of action needed to minimise the risk. The Manager must make sure that all residents fire evacuation risk assessments are up to date. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. EVIDENCE: The Inspector looked at two residents files that included a weekly programme of individual activities. During this inspection, staff supported three of the six residents to access activities in the local community. The other three residents were being escorted out into the community that afternoon to participate in different activities including a dance class, a trip in the residents own car and out for lunch. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 12 The Inspector saw details of resident’s relatives, friends and other significant people recorded in the care plan file and the Manager confirmed that they make sure individuals stay in contact with these people. One person goes home every weekend to stay with their parents and staff provides support to enable this. The Manager confirmed that all of the people living in the home had a holiday. The Manager talked to the Inspector of a trip to Sherwood Forest that he had escorted some of the residents to, confirming everyone had a good time and participated in lots of activities. The Inspector saw menus on each floor that had been put in place by residents and staff. The weekly menu was seen to be varied and had different meals to suit all of the residents cultural requests. On the day of this Inspection residents were seen to be helping themselves to drinks and snacks with the assistance of staff when requested. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. EVIDENCE: Both service user care plan files checked by the Inspector included a healthcare needs checklist that details appointments with the person’s GP, dentist, optician and clinicians from the Learning Disability Team. The checklists seen were well completed and are evidence that staff respond to health care issues appropriately. The Manager reported that they are now encouraged to be more flexible when supporting residents, to make sure that same gender care is usually given. Both files also included detailed guidance for care staff on the way in which the residents communicate. Detailed care guidelines also highlight known triggers that may cause distress or anxiety and ways that these can be avoided. Risk assessments were in place with action plans to inform staff of what action to take if a situation arose. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 14 The Inspector saw detailed behavioural plans that had been put in place for staff to follow by a psychologist, the Manager told the Inspector that the plans were very good and all staff worked with them. A health care professional returned a survey sent out as part of this inspection. They commented that staff communicate clearly and work well in partnership, and follow specialist advice given in the residents care plan. The Inspector checked the medication records for all of the people living in the home. The records were well maintained and all records were completed accurately. There is a need for all staff to make sure that the date is written on any bottles opened. Medication records for medication that is not in appliance aids should be clear; the reverse side of record sheet should not be used. The Inspector discussed the improvement in the medication records with the Manager who stated that they are regularly looked at by him and the deputy Manager. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in different formats including pictorial and other languages if required. EVIDENCE: The Manager confirmed that there have been no adult protections incidents or investigations since the last inspection. The Manager told the Inspector that all staff except a new team member had completed POVA training; the training date for that member of staff had been confirmed by the training department. The Inspector discussed putting a file together with all of the relevant procedures for staff including the details of the local authority contact for staff to use if a safeguarding incident did occur. There have been no complaints in the last 12 months. Complaint information was available in different formats including pictorial. Three surveys returned by family all stated that they were aware of the complaints procedure but had no reason to complain and were happy with the care provided by staff for their relatives. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets specific needs of the people living there. The home is clean, however a programme to improve the decoration, fixtures and fittings is now required. EVIDENCE: The Inspector had a full tour of the home and was told by the Manager that he was putting forward a request for the communal areas to be decorated. The Inspector saw broken furniture in some areas that need to be replaced or repaired by the organisation. One of the residents mattresses was very strong smelling and does need to be replaced immediately with one specifically suited to their continence requirements. The home was clean and tidy on the day of this inspection, there is an issue that kitchen cupboards need to be cleaned inside. The homes curtains and net curtains need to be replaced in some areas and cleaned in others. Resident’s bedrooms were seen to have personal items including pictures, photographs and furniture. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough staff available to\meet the needs of the people using the service, with more staff available at peak times of activity. EVIDENCE: The Inspector looked at the staff rota and adequate staffing levels were in place to meet the care needs of all residents. During this visit the home’s Manager and deputy manager were working day shifts. Three care staff were also working day shifts and two other staff were working late shifts to 9:00 pm. At night there is one waking night staff and a second person on call in the home. The Manager confirmed that all staff have obtained an Enhanced Disclosure from the Criminal Records Bureau, the Inspector was sent a copy of all staff working at the home including any bank staff. The home has passed the target for 50 of the staff completing their NVQ training. Staff on duty during this visit demonstrated a good understanding of the care needs of individuals and all worked well together as a team to make sure that care needs were met. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 18 In discussion with the Manager and looking at staff training records it was apparent that staff is required to attend mandatory refresher training. The Manager discussed the new training programme with the Inspector and stated that all staff will be nominated to attend the relevant training. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is qualified and has the necessary experience to run the home. Health and safety records show that not all checks are up to date. EVIDENCE: The home’s Manager is registered with the Commission he has many years experience and has the Registered Managers Award. The Manager is supported by a Deputy Manager and a highly skilled team. The two care plan files reviewed by the Inspector during this visit each contained a quality assurance questionnaire completed during 2007. People independent of the home supported the residents to record their views on the services and support they receive. One questionnaire was completed with support from a former member of staff and this included some excellent comments that reflected the resident’s views. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 20 A selection of health and safety records was checked and these were well completed. There is an issue that fire alarm checks should be completed on a regular basis to make sure it is functioning correctly. The Manager must update the risk assessment to include the resident that moved into the home in 2007. The Inspector checked the finances of two residents, all of the receipts and transactions were up to date and the correct balance was in place for each. One issue was discussed with the home’s Manager during this visit, that the mattress that needs replacing is provided by the organisation and not the resident. Dry food packages that have been opened should be kept in sealable containers for safe storage; the Manager discussed this with a member of staff and requested they purchase containers when they were going shopping. Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 21 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 2 x Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 22 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 YA24 Regulation 23 Requirement Timescale for action 08/06/08 2 YA24 23 3 YA24 23 The organisation to schedule the home to be decorated in all communal areas to make sure that all of the people living at the home are comfortable in the environment. The organisation to provide new 08/04/08 furniture or repair all of the furniture that is broken throughout the home. The organisation to purchase a 08/03/08 new mattress for one of the residents. The Manager must make sure that all staff is up to date with mandatory training to ensure they are fully skilled in the care they provide to all residents. The Manager to check weekly fire alarm checks are happening and records completed in the relevant time period. The Manager to make sure that all dry foods opened are kept airtight containers. 08/04/08 4 YA35 18 5 YA42 23 08/03/08 6 YA42 16 08/03/08 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 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. 1. Refer to Standard YA12 Good Practice Recommendations The Manager to put in one place, all relevant information on protecting vulnerable adults including the local authority procedure. To make sure all staff are completely aware of the procedure to follow and who to notify if an incident occurs. The Manager to clean or replace curtains and nets throughout the home, as some are looking worn and dirty. 2 YA24 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Becklow Road DS0000019147.V342853.R01.S.doc Version 5.2 Page 25 - 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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