Inspection on 29/09/05 for Bishops Road, 89

This inspection was carried out on 29th September 2005.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishops Road, 89 12/02/07

Bishops Road, 89 20/02/06

Bishops Road, 89 15/02/05

Bishops Road, 89 23/08/04

Bishops Road, 89 17/10/03

Bishops Road, 89 16/05/03

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, 89 Hayes Middlesex UB3 2TG Lead Inspector Mrs Rekha Bhardwa Unannounced Inspection 29th September 2005 09:30 Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 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.V252916.R01.S.doc Version 5.0 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.V252916.R01.S.doc Version 5.0 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 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.V252916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2005 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. There was one vacancy on the day of the inspection. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process by Rekha Bhardwa. A total of 4.50 hours was spent on the inspection process. The Inspector carried out a tour of the home, and inspected service user plans, staff files, medication and other records required by regulation. 1 service user, 2 staff and the Registered Manager were spoken with as part of the inspection process. The pre-inspection documentation completed by the home was also examined to inform the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 6 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.V252916.R01.S.doc Version 5.0 Page 7 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): 1,2,3 & 4 Service users are provided with information about the home. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. Service users needs are assessed in order that the home can meet their needs. EVIDENCE: A Statement of Purpose and Service User Guide were available and all service users also have a copy of both documents in their bedrooms. The Registered Manager stated that she had been in the process of assessing potential service users for the two vacancies in the home. All referrals are received via the Community Team for People with Disabilities, along with the referral the Registered Manager receives a needs led assessment. Once she has received this a visit is arranged to meet the potential service user and for the home to undertake their own assessment in order to establish whether the service users needs can be met. Prospective service users have an opportunity to visit the home, meet other service users and the staff working in the home. Service Users have access to specialised services and professionals. This includes Psychiatrists and Psychologist. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 8 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): 6,7,9 & 10. There is a clear care planning system in place, which provides the staff with the information they need to meet the needs of the service users. The home has a good risk management system in place, which protects the safety of the service user. Systems are in place for service user consultation and participation in the home is promoted, this allows the service user to be valued and respected. EVIDENCE: The service user plan for one service user was viewed. This was comprehensive and detailed the care that was required. There was evidence that the service user plan was being reviewed. The Registered Manager stated that service users are encouraged to make decisions about aspects of their daily lives. This includes what time they go to bed, what activities they participate in, where they choose to spend their time Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 9 and what clothes they wear. The service users are also encouraged to make decisions about the weekly menu, and what type of annual holiday they like. The level of participation in the home by the service users varies due to their age and ability. Where possible some service users tidy their bedrooms, dust and polish. Specific risk assessments relating to service users were available along with generic risk assessments. A confidentiality policy and procedure was in place. Service users records are held securely. Staff do not enter bedrooms or bathrooms without knocking first. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 10 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): 11,12,13,14,15,16 & 17 Service users participate in a range of activities that meet their individual needs. The home promotes individuality, positive relationships between service users and their families and supports service users to have a lifestyle that suits their individual needs and preferences. Meal provision in the home is good offering variety and catering for special dietary needs and involving service user participation. EVIDENCE: There was evidence that staff work hard in enabling service users to maintain and develop the service users social skills within their individual capabilities. The home is well integrated into the community. The home accesses local amenities that are suitable for the service users to access and meet their individual needs. This includes visiting the library; local pubs, shops, Beck Theatre, cinema, day trips and service users have an annual holiday. Individual and group activities take place. Group trips to Windsor and Hampton Court took place over the summer. The home uses dial-a-ride in Hillingdon when required. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 11 At the time of the inspection three service users were attending day centres. One service user was at home at the time of the inspection. Evening clubs can also be accessed. Family links and friendships were encouraged and maintained by the home. Service users visited family members, were taken out by them or visited the home. The Registered Manager said that all interested family members were invited to annual reviews. Bedroom keys are available for all service users but at the present time no service user has chosen to have a key. Mail received is handed to the service user unopened. Staff respect the service users privacy and knock on bedroom doors before entering. Decisions around daily routine are encouraged, this includes choosing clothing, food, activities, shopping and what the service users would like in their bedrooms. Where possible the service users have chosen the décor within their individual bedrooms. The Registered Manager stated that two service users are able to help with making tea and coffee in the kitchen. One service user participates in preparing packed lunches. The service users are involved in developing the weekly menu and where possible going shopping. Service users are weighed monthly. A low salt diet is provided for one service user and the staff aim to promote healthy eating. Snacks and drinks are available throughout the day. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 12 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 & 20 Personal support is offered in such a way as to promote service users’ privacy, dignity and independence. Overall the health care needs of service users are well met with evidence of good multi disciplinary working. The systems for the management of medication were in place and well managed and therefore safeguarding service users. EVIDENCE: Individual personal care needs are assessed and recorded in the care plan. Where required the staff provide support and guidance. Likes and dislikes in relation to personal care are also recorded. Suitable adaptations were available throughout the home. At the time of the inspection all service users were fully mobile. The pre-inspection questionnaire indicated that the service users have access to all healthcare professionals. This includes the GP, District Nurses, Occupational Therapist, Physiotherapist, Optician, Psychiatrist and Chiropodist. An annual health check is undertaken via the Wellman Clinic or via the GP. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 13 At the time of the inspection one service user was able to self-administer their medication. The home uses the Boots Monitored Dosage System. Medication was well stored and the Medication Administration Records viewed were well recorded. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 14 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 & 23 The home has a good complaints system in place, whereby service users and their representatives are able to raise concerns. Systems are in place for the Protection of Vulnerable Adults, which protect the service users from abuse. EVIDENCE: The home has a clear complaints procedure and this has been made available to all service users. The home or the Commission has received no complaints since the last inspection. The home has a clear procedure for the protection of vulnerable adults (POVA), and this dovetails with the Local Authority documentation. All staff within the home had received training in abuse awareness. Records are maintained of service users finances and these were viewed by the Inspector. Receipts are also kept of any goods purchased on behalf of the service user. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 15 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): 24,25,26,27,29 &30 The overall standard of the environment within this home is good providing service users with an attractive, comfortable, safe and homely place to live. The home is clean and hygienic. EVIDENCE: A tour of the premises was undertaken during the inspection. The home was clean, hygienic, safe and well maintained. Individual bedrooms viewed were well decorated with colours chosen by the service users. The quality of furniture and fittings was good. One service user required an electric bed and this has been purchased by the home. Sufficient space is available in the service users bedrooms for their stereos, televisions, compact discs and other personal items. The service users have a lounge/dining room on the ground floor. This was homely and comfortable. There is also a small rear garden, which can be accessed by all service users via the lounge or ground floor corridor. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 16 Each service user has a washbasin in their bedroom. Sufficient bathrooms and toilets are available to meet the needs of the service users. Suitable adaptations are available throughout the home. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 The home was adequately staffed to meet the assessed needs of the service users. The service users are well supported by a well-established staff team, which is well managed, supported, supervised and effective in meeting the individual and joint needs of the service users. The provision of in house training is good and ensures that the identified training needs of individual staff are addressed and that staff have the necessary skills to meet service users needs. EVIDENCE: Three members of staff have completed their NVQ Level 2 training. Some of the care staff have worked in the home for a number of years and know the service users well and which approaches to use when working with the service users. On the day of the inspection the staffing levels were appropriate to meet the needs of the service users. No changes have been made to the number of staff on duty since the last inspection. One staff file viewed contained an application form, two references, proof of identity and a CRB check. Health questionnaires are completed and sent to an Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 18 Occupational Health company used by the Registered Provider. Head Office then receives a certificate from the Occupational Health Company as to whether the staff member is fit for the purpose of the job. It is recommended that a copy of this certificate be kept with the staff records at the home. The post of Deputy Manager has been vacant for over 12 months. Ongoing recruitment has been taking place to fill this vacancy. The pre-inspection questionnaire detailed the training that had been undertaken by staff. This included POVA training; all mandatory training and the Registered Manager had completed her Registered Managers Award. The Registered Manager stated that she had a system of formal staff supervision. Records of supervision sessions are kept, and signed by the supervisee and the supervisor. There is also ongoing supervision with the staff working on the floor this includes working alongside staff and discussing care issues. The home also has an appraisal system in place. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 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): 37,38,39,40,41 & 42 The home is well managed and the Registered Manager has an open style of management. Meeting the service users needs is a priority with all staff and there is good support from the management team. Staff work together to meet the needs of the service users. The shortfalls in the Legionella testing could pose a risk to service users and staff EVIDENCE: One member of staff confirmed that the Registered Manager has an open management style, is approachable, positive and promotes an inclusive atmosphere. The Registered Manager works alongside the care staff in meeting the service users needs. As part of the quality assurance system the policies and procedures within the home are periodically reviewed. The results of the service users surveys had Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 20 been published. Regulation 26 Visits had been taking place and reports of these visits had been sent to the Commission. Individual and generic risk assessments were in place. The accident book was viewed and found to be satisfactorily recorded. Regular Health and Safety Audits were taking place. The last recorded fire drill practice was dated 17/9/05. There was no evidence that Legionella checks had been undertaken. All other servicing records viewed were satisfactory. Overall the records viewed in the home were well maintained, systematic and easily accessible. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bishops Road, 89 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 x DS0000027073.V252916.R01.S.doc Version 5.0 Page 22 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 YA42 Regulation 13(4)c Requirement Legionella testing must take place, records of this test must be kept at the home and available for inspection. Timescale for action 28/11/05 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 YA34 Good Practice Recommendations It is strongly recommended that a copy of the Health Certificate held at Head Office is kept with the staff records in the home. Bishops Road, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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, 89 DS0000027073.V252916.R01.S.doc Version 5.0 Page 24 - 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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