CARE HOME ADULTS 18-65
Bishops Road, 89 Hayes Middlesex UB3 2TG Lead Inspector
Ms Jean Bovell Key Unannounced Inspection 15th February 2007 11:30 Bishops Road, 89 DS0000027073.V327976.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, 89 DS0000027073.V327976.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, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bishops Road, 89 Address Hayes Middlesex UB3 2TG 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) 020 8561 0260 020 8561 0260 www.lifeopportunitiestrust.co.uk Life Opportunities Trust Ms Linda Hanaghan Care Home 5 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Bishops Road is a home registered to give board and personal care for five adults with Learning Disabilities. The home is operated by Life Opportunities Trust and owned by Shepherd’s Bush Housing Association. It has been registered since 1996. The home is situated in a residential area on a bus route, close to shops, day centres, clubs and other local amenities. Three service users attend day care services. One service user has made a positive choice not to attend day care services. The home has a small garden area that service users use when the weather allows. The home does not offer any respite care. Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 15th February 2007. Three care support workers and one service user were at the home. The Inspector was informed that the Registered Manager was on sick leave and that four service users were attending the day centre. During the course of the inspection, the home’s records, documents, policies and procedures were examined. A tour of the building was undertaken and observations were made. Five care support workers who covered separate shifts at the time of the inspection were spoken with and all key Standards were inspected. What the service does well: What has improved since the last inspection? What they could do better:
Four requirements were identified at this inspection and related to incidents and accidents, and financial records and quality assurance. Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 6 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, 89 DS0000027073.V327976.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, 89 DS0000027073.V327976.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The separate needs and aspirations of prospective service users are satisfactorily assessed prior to admission into the home. EVIDENCE: The records relating to the most recent service user admitted into the home were inspected. It was evidenced that background information and an initial assessment that had been carried out by the placing Authority was submitted at the point of referral. A needs led assessment was subsequently undertaken by the home and indicated that a prospective service user, relatives, social workers and medical professionals participated in identifying and assessing separate personal, health care, cultural/religious needs and social interests. Bishops Road, 89 DS0000027073.V327976.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): 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. Care plans and risk assessments are appropriately undertaken and regularly reviewed. Service users receive encouragement and support with making decisions regarding their daily living routines. EVIDENCE: Care plans relating to three service users were viewed. It was reflected that individual personal and healthcare needs were assessed and social interests were identified. Actions required and outcomes had been recorded. Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 10 Risk assessments associated with specific activities identified within care plans such as moving and handling, had been undertaken. All care plans and risk assessments were regularly reviewed. The Inspector was informed by a care support worker that service users were offered choice in relation to meals, activities, clothing, hairstyles and when they got up in the morning and retired at night. One service user who was at the home during the inspection had chosen not to attend the day centre and personal choices and interests were reflected in individual service users’ bedrooms. Bishops Road, 89 DS0000027073.V327976.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): 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. Service users are able to participate in appropriate indoor and outdoor activities. Service users rights are respected and contact with relatives are being maintained. Varied and wholesome meals are provided to the service users. EVIDENCE: A care support worker confirmed that of the five service users at the home four attended the day centre on a regular basis and it was evidenced on records
Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 12 viewed that they were able to participate in various courses at the day centre such as pottery, literacy, horticulture and vocational development. Service users were also supported during shopping trips, the cinema, meals out, day trips and annual holidays. Separate indoor activities included music, DVDs, TV, drawing and card games. An open visiting policy was in place and it was evidenced on care plans that relatives regularly visited the home and service users also visited relatives’ homes. A care support worker confirmed that service users received unopened mail and were able to make and/or receive telephone calls. Service users also carried out housekeeping tasks such as tidying their bedrooms, bringing down their laundry, emptying the dishwater, preparing vegetables and hot/cold drinks. One service user regularly made packed lunches for himself and everyone else who attended the day centre. Varied and wholesome meals were reflected on the menus and an appealing and nutritional lunch was observed being served to a service user at the time of the inspection. Bishops Road, 89 DS0000027073.V327976.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): 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. Service users privacy and dignity are being upheld during the delivery of personal care and their physical and emotional needs are being appropriately met. The home’s policy and procedures on medication are satisfactory. EVIDENCE: It was indicated on care plans that the service users required assistance with their personal care routines. A care support worker confirmed that personal care needs were met in privacy within bedrooms or bathrooms but service users were able to choose what they wore, hairstyles and make-up.
Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 14 Individual health care needs were identified within care plans and it was evidenced that service users received access to the GP when required and were accompanied during medical appointments. Regular dental, optical and chiropody checks were arranged. The policy and procedures on medication were in place and the records indicated that medication training had been delivered to the care support workers. The storage, disposal and administration of medicines were satisfactory. None of the service users were capable of self-administering their medication at the time of the inspection. Bishops Road, 89 DS0000027073.V327976.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): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Complaints procedure is appropriately detailed. Records relating to accidents and incidents and financial records are not being satisfactorily undertaken. EVIDENCE: The Complaints procedure is clearly detailed and accessible to the service users and their relatives. It was indicated in the complaints book that no complaints had been made to the home since the last inspection. Life Opportunities Trust policy and procedures on Health and Safety were in place and a Health and Safety Poster was displayed at the home. Accidents and incidents sustained by service users were recorded as required but related risk assessments were not appropriately detailed and accident sheets relating to service users who no longer resided at the home had not been removed from current files.
Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 16 The financial records of four service users were examined at random. It was found that in some cases, income and outgoing expenditure were not specifically indicated, clearly detailed or reflective of Life Opportunities Trust written policies. These matters were discussed with the Responsible Individual and the Inspector was assured that appropriate action would be taken. Bishops Road, 89 DS0000027073.V327976.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): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, safe and homely. EVIDENCE: The home is adequately spacious, comfortably furnished, in good decorative order and suitable for shared and/or individual activity. The garden was well maintained and accessible to the service users Overall, the home was found to be clean and hygienic and there were no issues regarding the laundry. The atmosphere was calm and homely. Bishops Road, 89 DS0000027073.V327976.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): 32, 33 and 34. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed and care support workers are appropriately trained and qualified for meeting the needs of the service users. EVIDENCE: The records indicated that five permanent care staff and two care staff that were on fixed-term contacts were employed at the home. The rotas were reflective of two care staff being on duty during waking hours and one sleeping cover at night. Three care support workers were on duty during and early shift at the time of the inspection and included one newly appointed contract worker who was receiving induction training.
Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 19 Individual training programmes were in place and there was documented evidence that two care support workers had achieved NVQ2 in health and social care and one care support worker had commenced NVQ2 training. It was also indicated that recent staff training including Protection of Vulnerable Adults, Moving and Handling, Fire Safety, First aid, food hygiene, Resuscitation and equality and cultural diversity, Care support workers were observed being attentive and competent in meeting the needs of a service user who was at the home throughout the inspection. The Registered Manager was not at the home during the inspection and as a consequence, confidential recruitment files were not accessible. However, no requirements relating to home’s recruitment policy and procedures were identified at previous inspections. Bishops Road, 89 DS0000027073.V327976.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): 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 Registered Manager is suitably experienced and qualified. Quality assurance systems were not in place. The health and safety of the service users are being protected as required. EVIDENCE: The Registered Manager was not present during the inspection but it was reflected on training records that she had obtained the Registered Managers Award.
Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 21 Care support workers reported that The Registered Manager had been in post for approximately 10 years and that she was approachable and supportive. Systems indicating that quality assurance exercises had been undertaken during 2006 or currently were not evidenced at the time of the inspection. All health and safety records viewed were up to date. These included gas maintenance, portable appliance tests, water temperature and fire safety checks. Fire drills were regularly undertaken and appropriately detailed. Fire risk assessments had been carried out satisfactorily. Bishops Road, 89 DS0000027073.V327976.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 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 X 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Bishops Road, 89 DS0000027073.V327976.R01.S.doc Version 5.2 Page 23 No 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 YA23 Regulation 17(2) Requirement Timescale for action 30/03/07 2 YA23 3 YA23 4 YA39 The Registered Person must ensure that financial records are clearly and specifically detailed. 17(3)(a) The Registered Person must 30/03/07 ensure that accidents and incidents records regarding past services users are removed from current files. 13(4)(c) The Registered Person must 30/03/07 ensure that risk assessments in relation to accidents or incidents are appropriately carried out. 24(1)(a)(b) The Registered Person must 30/09/07 ensure that quality assurance exercises are carried out at appropriate intervals. 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, 89 DS0000027073.V327976.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
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