Inspection on 26/09/07 for Bishops Road, 172

This inspection was carried out on 26th September 2007.

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

Other inspections for this house

Bishops Road, 172 15/05/06

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 26th September 2007 09:30 Bishops Road, 172 DS0000019143.V341260.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 Bishops Road, 172 DS0000019143.V341260.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. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 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 jonathan.parkin@yarowhousing.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.V341260.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 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 resident, 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. The weekly fee for Bishops road is £1.043.35. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 26th September 2007; the inspector spent 4.00 hours visiting the home. The Inspector spent time with the Manager and all four residents. The Inspector looked at the records of two residents and two staff members. All of the resident’s medication and finance records were checked. All of the residents 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. The CSCI received questionnaires from residents and their families, comments and information received will be included throughout this report. 6 of the 7 requirements that were set 15/05/06 have been met; four new requirements have been made from this visit. What the service does well: What has improved since the last inspection? Magnetic fire doors in kitchen and the lounge have been fitted; this has stopped the practice of staff and residents wedging open fire to have clear access into the lounge and kitchen. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 6 The requirements for the decoration in certain areas of the home has been completed. All water thermostats have been checked as some outlets were to hot. The Inspector looked at weekly records of temperatures and checked the water temperatures in the four residents bedrooms, all were set at the correct safe temperature. 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. Bishops Road, 172 DS0000019143.V341260.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 Bishops Road, 172 DS0000019143.V341260.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): Standards 1 and 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a Statement of Purpose that sets out some of the aims and objectives of the home. The Statement of Purpose does not include all of the required information for prospective residents to make an informed decision on whether to live at Bishops Road. EVIDENCE: The Inspector looked at the Statement of Purpose and Service User Guide, the Statement of Purpose is very condensed with only basic information about Bishops Road. The Inspector showed the Manager the required information that should be in the document as stated in Schedule 1 of the Care Home Regulations 2003. The Inspector looked at the records in one resident’s file that had recently moved into Bishops Road. The information in place showed that introductory visits had taken place with notes to show how the staff other residents interacted. The care plan and referral records were informative showing the residents needs, looking at their aims and aspirations and showing and how the staff at Bishops road were going to assist in meeting them. Bishops Road, 172 DS0000019143.V341260.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 if agreed. It is kept up to date and focuses on how individuals will develop their skills and considers future aspirations. EVIDENCE: “My sister has made giant steps since living at Bishops Road, its excellent”. “”Staff promote independence and assist people to be proud of who they are”. The Inspector looked at two residents files and their last Person Centred Planning records. 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. The (PCP) information is now gathered form lots of different sources with pictures, photographs and the resident either using drawings or assisted with multimedia. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 10 The Manager told the Inspector that (PCP’s) were very familiar to three of the residents and that staff were working closely with one resident to assist in familiarising her with all of the different ways to collate information for her plan. The Manager told the Inspector that three reviews were up to date and they were waiting for an allocated care Manager to attend the final review. The Inspector spoke to all of the residents who all stated they were happy living at Bishops Road. The Inspector observed residents living independently in the house, getting showered and dressed with little assistance and prompting. One resident commented that she liked her (PCP) meetings and that her brother attended. The Inspector saw risk assessments in place in the two files looked at, the risk assessments were varied from holidays, living at Bishops Road, participating in activities and behavioural issues. Review records were seen in both files, in discussion with the Manager the Inspector noted that some records had dates missing, the Manager stated that she would make sure all staff put dates on all records. All of the risk assessment had relevant actions in place to minimise any risk. There is a requirement that an up to date fire risk assessment be completed for all residents. Bishops Road, 172 DS0000019143.V341260.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. The service has a strong commitment to enabling people who use the service to develop their skills, including social, emotional, communication and independent living skills. EVIDENCE: “All of the staff and other residents are welcoming when I visit my sister”. The Inspector looked at activity plans for all four residents who have varied activities provided either in the community or by staff at Bishops Road or with family members. Weekly activity plans were on the notice board in the kitchen, the office and in each resident’s bedroom. All of the residents are escorted to go out daily to different venues including The Gate for art and drama classes, relaxation classes, dance classes, flower arranging and also other venues are attended frequently by the residents. In discussion with all of the residents they stated they were happy with all of their activities which they enjoyed doing. In discussion with the Manager the Inspector was told that literacy skills classes are starting up again and she was nominating residents to go as they have requested to attend. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 12 Cookery classes at one of the centres is now being offered again and residents told the Inspector they really enjoy attending these classes as they all assist in preparing meals in the home. The home had a TV, DVD, music centre and video in the lounge. The Inspector received questionnaires from residents and their families that stated that Bishops Road is always a welcoming place to go and people are made very welcome. In discussion with staff and residents the Inspector was told that family members of all the residents are always calling at the home. There is a weekly menu recorded, residents 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 all the residents had discussed menus. Menus were seen in the kitchen, all of the residents stated they enjoyed the food and they all assist in cooking, this is written on their activity plans. All of the residents were seen to make drinks and help themselves to breakfast and snacks when they wanted to. Bishops Road, 172 DS0000019143.V341260.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 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each residents plan; they give a comprehensive overview of their health needs and act as an indicator of change in health requirements. EVIDENCE: All of the residents are semi- independent and complete their own personal care needs with staff assistance, this is done either in the resident’s bedroom or in one of the bathrooms. All of the residents looked very smart and tidy on the day of the Inspection, residents told the Inspector that they choose what they want to wear. All service user health needs are being met, in discussion with the Manager and looking at records there are no issues at present with three of the residents. One of the residents however has had her medication changed numerous times lately by her GP; the Inspector was told by the Manager that this is having some adverse affects to her daily and nightly lifestyle patterns. The Manager told the Inspector that the resident is now waking up in the early hours and not going back to bed. All of the residents have a local GP and are supported to attend appointments. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 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.V341260.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 home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. Residents and others involved with the service say they are happy with the service provision. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. All four residents finances were looked at and some financial transactions had not been recorded making the balance on two of the resident’s records incorrect. In discussion with the Manager the Inspector was told that there are instances when receipts are not accounted for, as residents will keep them in their purses. One resident did have a receipt that had not been recorded on the financial transaction record. The Managers must make sure that all financial transactions are completed straight after a transaction has been completed for or with a resident. All staff has been trained in protection of vulnerable adults (POVA). The complaints records were checked and there have been no complaints in the last 12 months. The Inspector was shown quality questionnaires that all residents 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 residents told the Inspector that he would speak to the Manager or a member of staff if they had an issue or complaint. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 16 Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 17 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 24,25,28 and 30.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged to personalise their bedrooms. EVIDENCE: A full tour of the home was given and all of the residents showed the Inspector their bedrooms. All of the bedrooms were seen to be different with the resident’s individual tastes taken into account, with photographs, pictures and other personal possessions. All of the residents told the Inspector they were happy with the furniture. Two of the bedrooms have been decorated and the bathroom as required at the Inspection in May 2006. All of the residents clean their own rooms, on the day of the inspection one of the residents was happy to follow her plan and was doing her laundry, other residents were helping clean the kitchen, washing and drying dishes. The communal space in the home is decorated tastefully and was seen to be bright and clean. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34, 35 and 36.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The changing health needs of residents have had an impact on the staffing requirements specifically at night. The staffing levels need to be appropriate to meet those changing needs. EVIDENCE: The Inspector looked at the staff rota and in discussion with the Manager and looking at routines the staffing levels at present are not sufficient to meet the needs of the residents. As written in this report the health needs of one of the residents has recently changed and she is showing signs of severe anxiety. The Manager told the Inspector that this is causing a dramatic change to her sleeping pattern and the resident is waking in the early hours and getting up. The impact on staff is that they are scheduled for sleep in and rostered to do the early shift the next day, this is not appropriate at the present time and a waking night person should be on duty to meet the resident’s needs. The Manager told the Inspector that the resident does not like strangers and she would put together a support plan that introduces two new staff members in the day shifts to familiarise them with needs of the resident and for her to become accustomed to their presence in the home. This will have an impact on the immediate team as they will have to do waking nights in the interim period. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 19 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 Manager and looking at records all staff are up to date with mandatory training, however other training is not being completed by staff as they are working extra shifts due to a member of staff being absent. Two staff has NVQ qualifications with 3 staff working towards a qualification and 1 member of staff waiting to register. The Inspector looked at supervision records for two staff that show supervision is happening, the Manager told the Inspector that this was not as frequent as she would like however there is an open door policy at Bishops Road and staff will liaise with the Managers daily. All staff are up to date with their annual appraisals. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The Manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. EVIDENCE: The Manager has worked for Yarrow for many years and is very experienced; she has registered to complete a Registered Managers Award. The Inspector observed that the home was very open and friendly, staff and residents were working very closely and residents were supported in being independent. The Manager does have to register with the CSCI. There is an effective quality assurance monitoring system in place that was looked at by the Inspector, questionnaires were in the two residents files that stated the residents views on the services they receive in the home. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 21 Yarrow produces an annual document that is available to prospective clients 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 was an issue with water temperatures being to hot in some outlets, records show that this maintenance was done and outlets have been set at the correct safe temperature. The Inspector checked the water temperatures in each resident’s bedrooms that were set correctly. There is a requirement that a new up to date fire risk assessment has to be completed on all residents. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 22 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 3 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 2 x 3 x x 3 x Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation (4) (5) Schedule 1 Requirement The Statement of Purpose and Service user guide to be up dated, and a copy of each sent to the CSCI. This is a repeat requirement that was set 30/06/06. The Managers must check the financial transactions for all residents to make sure all staff are completing appropriately after every transaction. The Manager must put in place a waking night member of staff to meet the needs of all residents. The Manager must register with the CSCI. The Manager must update the fire risk assessments for all residents. Timescale for action 26/11/07 2. YA23 16 26/10/07 3. 4. 5. YA33 YA37 YA42 18 8 23 26/10/07 31/12/07 26/10/07 Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 24 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 YA41 Good Practice Recommendations The Manager must make sure all documentation has a date on it. Bishops Road, 172 DS0000019143.V341260.R01.S.doc Version 5.2 Page 25 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. 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