Inspection on 19/01/06 for Bishops Road, 172

This inspection was carried out on 19th January 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 4 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 15/05/06

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Bishops Road, 172 Bishops Road 172 Bishops Road Fulham London SW6 7JG Lead Inspector Jackie Derbyshire Unannounced Inspection 19th January 2006 10:30 Bishops Road, 172 DS0000019143.V278334.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.V278334.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 Older People and 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.V278334.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 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 Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 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 quite 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.V278334.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site inspection took place on the 18th January 2006. The inspector spent 2 hours looking at service user (PCP) Person Centred Planning records, financial, water temperatures and fire health and safety records. The inspector spoke to the 4 service users who are very happy with their surroundings; comments that were made are included in this report. Two service users bedrooms were seen with a tour of the rest of the house. What the service does well: What has improved since the last inspection? PCP records have improved and staff are now becoming more familiar with the procedure. Finance records are being checked on a weekly basis. The staff are checking food dates daily to make sure that the food is in date. The inspector was impressed with the fresh produce available at the home. The boiler has been repaired and water temperatures in all outlets are now at a safe temperature. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 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. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were assessed. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8 and 10 Person Centred Plans were seen to be up to date, with good use of photographs and other information in place. Service users were seen to be consulted with at all times in the home. There is a confidentiality policy in place that service users were happy with. EVIDENCE: The inspector looked at two service users PCP plans and review records were seen to be in place. The plans showed a good use of photographs. The inspector noticed a big improvement in the PCP records. In discussion with staff and service users the PCP reviews are now easier with different methods being used to collate information. A service user stated that she had a DVD of her last holiday that she liked to show people and had done in her last review. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 10 Checking records it was still an issue that staff need to be more familiar with goals set and all staff are made aware of these goals with outcomes monitored and reviewed as part of the PCP review process. The inspector checked the finance records for three service users, two of the records were seen to be correct one of the records was kept by the service user and she chooses not to have as much staff input as she likes to spend her money and sometimes does not get receipts. In discussion with the service user she stated that she works part time and likes to enjoy spending her small salary. There is a confidentiality policy in place with all records kept in the office. Service users spoken with were happy with staff stating that they were happy that staff were keeping their confidences and that they would discuss any issues with staff if they felt it necessary. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,14 and 17 The home has activity plans in place that show a varied mix of activities that is suitable for each service users needs. The meals offered by the home are good offering choice and variety. EVIDENCE: Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 12 All of the service users have a full activity plan that was written in their files, and seen on the kitchen and office notice boards. In discussion with the service users all of them stated they were happy with the activities they did. All four of the service users participated in various activities on the day of the inspection going to the library, literacy class and going to a lunch club. One of the service users was getting ready to go to work; she does cleaning in another Yarrow home that she stated she thoroughly enjoyed doing. 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. Service users spoken with stated that enjoyed the food and they helped to do the shopping, they also stated that at times they assisted to prepare meals. On the day of the inspection the service users were seen to make themselves snacks and drinks in the kitchen. One of the service users is attending cookery lessons and will bring cakes etc back for the service users and staff to enjoy. The fridge and freezer were checked and there was no out of date food that was a requirement from the last inspection. There was plenty of fresh food with a very good choice of fresh fruit and vegetables available. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these Standards were assessed. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 The home has an adult protection procedure in place that is known by staff and service users stated they would speak to a member of staff. EVIDENCE: The home has an adult protection procedure in place and staff spoken with were up to date in training and were aware of the procedure to follow if there was an issue. Service users spoken with stated they would speak to a member of staff if they had a problem. There have been no protection issues in the home for the last 12 months. Three service users finances were checked and were seen to have all relevant records in place with the correct balance shown for each service user. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 The home is very comfortable and well decorated. Service users bedrooms have sufficient furniture and are decorated to suit the requirements of each of the 4 ladies. There is no specialist equipment used at the home at present. EVIDENCE: A full tour of the home was given and two of the service users bedrooms were seen, they were different with the service users individual tastes taken into Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 16 account. The service users were happy to show the inspector their bedrooms and stated they were very happy with the furniture and the décor. All communal areas are well decorated with appropriate furnishings; the home was clean and very tidy in all areas. There are sufficient toilet facilities in the house with 2 bathrooms one having a walk in bath; there is also a single toilet on the 1st floor. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These Standards were not assessed. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39 and 42 The home is well managed by both service users and staff who work extremely well together to make sure that the house is a home. The home does have monitoring tools in place, the organisation needs to collate all of the information and produce an annual Quality Assurance report. The Manager is well supported by staff to ensure all health; safety and welfare issues are met. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 19 EVIDENCE: In discussion with staff and service users the inspector was able to ascertain that the house is a comfortable safe environment in which all service users stated they felt safe and secure. Service users all have tasks to complete as written in their care plans on the day of the inspection one service user was doing her laundry and another service user had tidied her bedroom of which both stated they were happy to do as it was their responsibility. All of the service users complete questionnaires and are able to communicate any issues they have by using the complaint procedure. In discussion with the service users they are happy at the moment as the boiler in the house has been repaired and this was the only problem they had had in the last 12 months. The organisation needs to collate all of the information for the homes quality assurance report. There is an issue in the home with the Kitchen and lounge fire doors as when they are closed the staff are unable to supervise service users at all times and this can be deemed as a risk. Magnetic doors would minimise any risk if placed on both doors as the inspector found the lounge door propped open the problem being that this seems to be common practice as when the staff removed the door wedge a service user went into the lounge and wedged the door open again. This must not happen, as the doors are fire doors. The door in the kitchen must be replaced, as it is no longer fire proof there is a large gap at the bottom of the door, this is an immediate requirement that must be met in 7 days. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT Standard No Score 37 x 38 3 39 3 40 x 41 x 42 2 43 x 2 x 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 x 14 3 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bishops Road, 172 Score x x x x DS0000019143.V278334.R01.S.doc Version 5.1 Page 21 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 YA6 Regulation 15 Requirement Staff must be made aware of the goals for individual service users and the outcomes must be monitored in reviews. An annual quality assurance report that is specific to Bishops Road is sent to the CSCSI. Magnetic fire doors in kitchen and the lounge to be fitted. This is a repeat requirement The fire door in the kitchen to be replaced as it is not fire proof. This is an immediate requirement. Timescale for action 18/03/06 2 3 4 YA39 YA42 YA42 12 23 23 31/03/06 28/02/06 25/01/06 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.V278334.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI. Bishops Road, 172 DS0000019143.V278334.R01.S.doc Version 5.1 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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