Inspection on 15/05/06 for Bishops Road, 172

This inspection was carried out on 15th May 2006.

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

Other inspections for this house

Bishops Road, 172 26/09/07

Bishops Road, 172 19/01/06

Bishops Road, 172 15/01/05

Bishops Road, 172 23/08/04

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 Bishops Road, 172 Bishops Road 172 Bishops Road Fulham London SW6 7JG Lead Inspector Jacqueline Derbyshire Unannounced Inspection 15th May 2006 09:30 Bishops Road, 172 DS0000019143.V291554.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 Bishops Road, 172 DS0000019143.V291554.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. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bishops Road, 172 Address Bishops Road 172 Bishops Road Fulham London SW6 7JG 020 7371 7808 NO FAX 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 Dan Kisumbi Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: 172 Bishop’s Road provides accommodation and support for four women with a learning disability, allowing them to lead as independent a life as possible in the community. The house is of 2 storeys, in a quiet residential road. The house is well maintained and attractively furnished and provides a comfortable home for the four people who live there. A programme of day activities is arranged for each service user, using local community and specialist resources. Care and support is provided by Yarrow Housing Ltd. The building is owned and maintained by the Notting Hill Housing Trust. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 15th May 2006; the inspector spent 4.00 hours visiting the home. The Inspector spoke with three of the service users who are very happy with their surroundings; comments that were made are included in this report. One of the service users it at the moment in hospital, staff and service users visit on a regular basis. The two staff members who were on duty assisted the Inspector with all requests and provided all of the relevant information. The Inspector checked the care records of two service users; two of the service users finance records, medication and all health and safety records. Three of the service users bedrooms were looked at and all communal parts of the home. The home provides a good standard of accommodation that was seen to be clean and tidy on the day of the inspection. There is an issue with magnetic fire doors being fitted in the kitchen and lounge areas not being done; an immediate requirement to complete the work has been set. 3 of the 4 requirements that were set 19/01/06 have been met, 6 new requirements have been made from this visit. What the service does well: What has improved since the last inspection? Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 6 Person Centred Planning (PCP) records were seen to be up to date with the aims and goals of the service users recorded. There is an effective quality assurance monitoring system in place. A new fire door has been fitted in the kitchen. 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. Bishops Road, 172 DS0000019143.V291554.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 Bishops Road, 172 DS0000019143.V291554.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): 1,2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides Statement of Purpose and Service user guide that needs up dating. EVIDENCE: The inspector checked the Statement of Purpose and Service user guide; both documents are clear however the documents need to be up dated. These documents are available in different formats including pictures if required. All prospective service user needs are assessed with their aims and aspirations looked at to make sure the home is suitable and that staff are adequately trained to be able to meet them. Contracts were in place for all four-service users that were signed and dated. Bishops Road, 172 DS0000019143.V291554.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): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person Centred Planning (PCP) records are all up to date with a lot of information in place some of the information is in photographs chosen by the service users. 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. EVIDENCE: Two service user files were looked at that had up to date information in place. In each Person Centred Planning (PCP) document there was a lot of information with specific aims for the person to be met in different time scales and who or how the home was going to assist in meeting the aims. Review records were up to date with records showing how some aims have been met, in discussion with one service user who stated that they had been on holiday to France and that one of their new aims was to go on another holiday. The service user stated that the staff assist her to be independent and on the day of the Inspection all three-service users were seen to participate in the running of the home. One service user went through her planning book and showed the Inspector photographs of herself with her friends and at various venues. In Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 10 discussion with the Inspector the service user commented that she liked her PCP meetings and that her brother attended. Risk assessments were seen to be in place for all of the service users that had been up dated when required, relevant actions were in place to minimise any risk. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Links with the community are good and support to enrich service users social and educational opportunities are in place. EVIDENCE: All of the service users have a full activity plan that was written in their files and also on the notice board in the kitchen and in each service users bedroom. All of the service users are escorted to go out daily to different venues including The Gate for art and drama classes, relaxation classes, dance classes and also other venues are attended frequently by the service users. In discussion with all of the service users they stated they were happy with all of their activities which they enjoyed doing. One of the service users attends a cookery class that she really enjoys however unfortunately the providers are stopping the classes. The service user has written them a letter of complaint as she really looks forward to this class and she meets up with friends there. The home had a TV, DVD and video in the lounge. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 12 In discussion with staff and service users it was stated that family members of all the service users are always calling at the home. Most weekends’ service users will either go to visit family and friends or they will come to see them at the home. There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced, this is done at the weekly residents meetings. The Inspector looked at the meeting book where menus had been discussed by all the service users. Menus were seen in the kitchen, all of the service users stated they enjoyed the food and they all assist in cooking the food this is written on their activity plans. All of the service users were seen to make drinks and help themselves to breakfast and snacks when they wanted to. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: All of the service users are semi- independent and complete their own personal care needs with staff assistance, this is done either in the service users bedroom or in one of the bathrooms. One of the service users told the Inspector that one of her aims was to be able to dress herself, which she is now able to do, the service user was very happy telling the Inspector. All service user health needs are being met in discussion with the staff team and looking at records there are no issues at present with three of the service users. One of the service users has been in hospital for a while; the staff and service users visit her regularly. On the day of the inspection one of the service users went to an opticians appointment. All of the service users have a local GP and are supported to attend appointments. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 14 The Inspector checked the medication administration records for all of the people living in the home. Overall the Inspector felt that the standard of medication recording was good with all staff following the medication procedure. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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 complaint procedure is available to all and is written in the Service user guide and was also on the notice board. There is a procedure in place at the home that is used for protection incidents that is known to service users and staff. 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 home’s Manager. All staff have been trained in protection of vulnerable adults. The complaints records were checked and there have been no complaints in the last 12 months. The Inspector was shown quality questionnaires that all service users have completed that ask if they are aware of the complaints, and all have stated they do and would complain if the need arose. Two of the service users told the Inspector that he would speak to the Manager if they had a complaint. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: A full tour of the home was given and three of the service users bedrooms were seen, they were all different with the service users individual tastes taken into account. All of the service users were happy to show the inspector their bedrooms and stated they were very happy with the furniture. Two of the bedrooms need to be decorated as shown by the service users. All of the service users clean their own rooms, on the day of the inspection one of the service users was happy to follow her plan and showed the inspector how clean and tidy her room was when she had done the cleaning tasks. The communal space in the home is decorated tastefully and was seen to be bright and clean. The 1st floor toilet needs to be decorated and the 1st floor bath needs to have a side panel put on it. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 17 Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 18 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 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Rotas show that sufficient staff are on duty at all times throughout the week. EVIDENCE: The Inspector looked at staff rotas and in discussion with the staff team and looking at routines was happy that the staffing levels at present are sufficient to meet the needs of the service users. The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff has up to date checks completed. Training and development plans are in place for all staff and in discussion with the staff team and looking at records all staff are up to date with training. All of the staff have completed an NVQ one member of staff stating that she is awaiting her work to be signed off by her NVQ Verifier. The staff stated that training has improved and that they are able to attend relevant training as discussed with the Manager. Records show that there is one vacancy at the moment for a Residential Support Worker; this vacancy is covered by regular bank staff and the rest of the team working extra shifts. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is supported by staff in providing a positive inclusive atmosphere. There are environmental health and safety areas that require attention from the Shepherd’s Bush Housing Association. EVIDENCE: The Manager has worked for Yarrow for many years and is very experienced; she is registered to start a Registered Managers Award in September to ensure she is appropriately qualified to run the home. The inspector felt that the home was very open and friendly, staff and service users were working very closely were service users were supported to be independent. There is an effective quality assurance monitoring system in place that was looked at by the Inspector, questionnaires were in the two service users files Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 20 checked that stated the service users views on the services they receive in the home. Yarrow produces an annual document that is available to prospective service users and any stakeholders whishing to see how the organisation works to develop a provision of care that is aiming to improve. Comments were seen from family members on the questionnaires that were very positive. All health and safety records were checked and all were seen to be up to date with any maintenance having been carried out. There is an issue with water temperatures being to hot in some outlets that need to be set at the correct safe temperature. There is an immediate requirement that has been repeated from 26/07/05 to have the kitchen and lounge doors fitted with magnetic fire closers to ensure that service users are supervised at all times. Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 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 2 2 3 3 x 4 x 5 3 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 3 25 x 26 2 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 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 Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 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 YA42 Regulation 23 Requirement Magnetic fire doors in kitchen and the lounge to be fitted. This is an Immediate Requirement The Statement of Purpose and Service user guide to be up dated, and a copy of each sent to the CSCI. Two service user bedrooms to be decorated. The 1st floor toilet to be decorated. The 1st floor bath to have a new side panel. Fire doors must not be wedged open at any time. All water thermostats to be checked as some outlets are to hot. Timescale for action 31/05/06 2 YA1 (4) (5) 30/06/06 3 4 5 6 7 YA26 YA27 YA27 YA42 YA42 23 23 23 13 13 31/07/06 31/07/06 31/07/06 15/05/06 22/05/06 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 Bishops Road, 172 DS0000019143.V291554.R01.S.doc Version 5.1 Page 23 Bishops Road, 172 DS0000019143.V291554.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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