Inspection on 11/07/05 for Brackenbury Road, 37

This inspection was carried out on 11th July 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 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

Brackenbury Road, 37 23/02/09

Brackenbury Road, 37 27/05/08

Brackenbury Road, 37 20/08/07

Brackenbury Road, 37 29/11/05

Brackenbury Road, 37 18/01/05

Brackenbury Road, 37 19/08/04

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 BRACKENBURY ROAD (37) 37 Brackenbury Road Hammersmith LONDON W6 0BG Lead Inspector Tony Lawrence Unannounced 11 July 2005 09:30 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 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 Stationary 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. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Brackenbury Road (37) Address 37 Brackenbury Road, Hammersmith, London W6 0BG Telephone number Fax number Email 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 8563 2125 Yarrow Housing Limited Care Home 5 Category(ies) of Learning Disability (5) registration, with number of places BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18 January 2005 Brief Description of the Service: Brackenbury Road is a registered care home providing accommodation and personal care for five men and women with a learning disability. At the time of this inspection there were four women and one man living in the home. Notting Hill Housing Trust owns the property and the care is provided by Yarrow Housing, a voluntary organisation. The home is well located, close to facilities in the local community and the shops and transport links of Shepherd’s Bush and Hammersmith. The home provides accommodation on four floors and is not accessible to people with mobility difficulties. Each person living in the home has a single room with wash hand basin and these are well decorated and furnished. Shared facilities include a bathroom, separate shower room, toilets, lounge, kitchen/dining room and garden. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 11th July 2005 from 09:30 – 14:00. The Inspector spoke with two service users, staff and the home’s manager. The care received by two people living in the home was tracked. Care records were checked and the Inspector saw all communal parts of the home and one person’s bedroom. People living in the home are well cared for and are supported to take part in a wide range of activities. Thirteen of the fourteen requirements made at the last inspection have been implemented. 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. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 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 standard(s) 1, 2, 3,4 and 5. The home provides good information for new service users. supported to make a positive choice to move into the home. EVIDENCE: The inspector checked the care plan file for one new service user who moved into the home in March 2005. The file includes a copy of the Service User’s Guide that has been produced in a format that is accessible to service users and a copy of the Tenancy Agreement. The service user told the Inspector that they had visited other homes but ‘liked this one best’. The manager and care staff confirmed that the service user had visited the home several times before moving in, before spending two overnights stays. The file contains assessments and reports written by health and social service staff responsible for the referral. The records of review meetings and assessments show that the service user was fully involved in each stage of their move to Brackenbury Road. The Inspector was impressed with the work completed by the person’s key worker and other staff to develop the service user’s Person Centred Plan (PCP). The Plan contained useful information about the person’s abilities and needs and how these would be met in the home. People are well BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 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 standard(s) 6, 7, 8 and 9. People living in the home are involved fully in planning the care and support they receive, but care plans must be regularly reviewed. The home’s risk management systems enable service users to live as independently as possible, but risk assessments must also be reviewed regularly. EVIDENCE: During this visit the Inspector reviewed the care plan files for two people living in the home. Both files were well organised and important information was easy to find. There was evidence in both plans that the service user has been fully involved in the review and planning of the services they use. Staff in the home record the care received by service users in individual daily Log Books. Staff on each shift are expected to update these records and entries are related to issues covered in the care plan. Staff are expected to record specifically examples of how each person is supported to make meaningful choices and how they are supported to be as independent as possible. One of the care plans checked was for a service user who moved into the home in March 2005. The plan included good examples of staff supporting this person to sample new activities and services as a way of agreeing longer term goals to be included in the plan. The second plan was for a person who has lived in the home for some time. This plan was written in February 2004 and although the plan has not been reviewed since, a review was held with the local authority’s BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 9 Placement Monitoring Officer. The service user and their key worker also carried out some good work in November 2004 to complete a Planning Book for the care plan review. There is a need to build on this good work to ensure that care plans are regularly reviewed and clear goals are included. Staff told the Inspector that service users are involved in planning activities, weekly menus and their own holidays. One service user is also paid for taking part in interviews for new staff. The two care plans reviewed by the Inspector included detailed risk assessments and clear guidelines for staff on how individuals should be supported in the home and the wider community. Known risks to individuals are well recorded and assessed and clear actions are included to minimise the risk. There is a need to ensure that individual risk assessments are regularly reviewed, especially after significant incidents affecting people living in the home. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15, 16 and 17. People living in the home are supported well by staff to take part in a wide range of activities in the home and the local community. EVIDENCE: The two care plans reviewed during this inspection each included a weekly programme of activities, both in and outside the home. The home’s Person Centred Planning systems enable service users to tell staff about their interests and aspirations and these are well recorded. If service users are unable to communicate verbally with staff, their methods of communicating are well known to staff. Some people living in the home use signs from the Makaton Vocabulary, a language system developed for use by people with a learning disability. Staff have access to Makaton training and examples of key signs and symbols are displayed around the home. The Inspector also saw staff using signs and speech to encourage service users to communicate their needs. The daily log books completed by staff show that people living in the home are making regular use of local cafes, pubs, cinemas and clubs. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 11 Details of service users’ relatives and friends are well recorded and the log books show that people are supported to keep in touch with significant people. Issues about service users’ sexuality are recorded as part of their care plans and appropriate referrals are made to specialist support services, if required. Care plans also include the service user’s wishes regarding an annual holiday. On the day of this inspection, one service user was due to return from a week’s holiday and staff told the Inspector that two other people living in the home had returned from their holiday the week before. Staff told the Inspector that arrangements have also been made to ensure that the other two people living in the home have a holiday later in the year. The last inspection report included a recommendation that photos should be used to make the weekly menu more accessible to people living in the home. One service user and staff told the Inspector that menus are discussed and agreed at weekly house meetings. The current menu includes some photographs and the manager confirmed that this would be extended. At the time of this inspection, major work was being carried out to refurbish the home’s kitchen / dining room. During the inevitable disruption, staff were supporting service users to go out for meals or choose foods from local cafes and take aways. Staff told the Inspector that they were aware of the importance of a varied and nutritious diet. They said that service users were supported to eat healthily and in one case, a service user was supported to lose a significant amount of weight. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Service users’ health and personal care needs are well met by staff. The staff team has also established good links with local specialist services, ensuring that service users get appropriate treatment and support. EVIDENCE: The Inspector felt that service users’ personal care needs are well assessed and recorded as part of the home’s person centred planning systems. Staff have ensured that the ways in which individuals prefer to be supported are recorded in their care plan. The two plans reviewed by the Inspector included clear guidance for staff on how each person should be supported at important times of the day – getting up and going to bed, meal times, going out and time spent in the home. The care plans show that people are encouraged to be as independent as possible and risk assessments are used well to ensure that individuals are safe at all times. Staff in the home have made good links with the local multi-disciplinary Learning Disability Team and appropriate referrals are made to clinicians, when required. The Inspector checked the medication records for four people living in the home. The standards of medication management have improved since the last inspection, records are well maintained and no errors were seen. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 13 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 standard(s) 22 and 23. The home has a clear complaints procedure that is accessible to people living in the home. There is some evidence that service users’ views are listened to and acted upon. EVIDENCE: The home’s complaints procedure has been produced in a format using pictures and Plain English that makes it more accessible to some people living in the home. The procedures are clear and support is available to enable service users to make a formal complaint about the services they receive. Since the last inspection there have been no formal complaints from people living in the home, their relatives or neighbours. Staff told the Inspector that disagreements between service users would be dealt with by the staff on duty and may be recorded in the individuals’ daily log books. The Inspector felt that some good progress has been made by the manager and staff to implement the organisation’s person centred planning systems. These focus on the service user’s wishes and aspirations and these are well recorded in the plans that have been produced. The daily logs books used by staff have been reorganised to ensure that staff record specific examples of how service users are supported to make choices about their care. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 14 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 standard(s) 24, 25, 27, 28 and 30. Work has started to significantly improve communal areas in the home, creating a comfortable and safe environment for service users. Overall, the home provides a good standard of accommodation. EVIDENCE: Brackenbury Road is an end-terrace property close to the shops and transport links of Shepherd’s Bush and Hammersmith. The home is not accessible to people with restricted mobility, as there are stairs to the main entrances and internal stairs to bedrooms, bathrooms and communal areas. The Inspector saw all communal areas and one service user agreed that the Inspector could see their bedroom. All parts of the home seen during the inspection were well furnished and decorated, especially the service user’s bedroom. Work has started to refurbish the kitchen / dining area and this will greatly improve this area. There is a sufficient number of toilets and bathrooms situated close to service users’ bedrooms and communal areas. The home has a part-time cleaner and all parts of the home seen during this inspection were clean and tidy. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 35. Despite a period of instability within the staff team, a group of experienced staff now offers consistent care and support to people living in the home. Details of Criminal Record Bureau checks must be kept in the home. EVIDENCE: Since the last inspection there have been some significant issues affecting the home’s staff team. Following two adult protection enquiries, two members of staff have been suspended and these posts are being covered by bank staff from within Yarrow. The Commission has been involved in a series of adult protection meetings and the Inspector feels that both incidents have been managed satisfactorily by the organisation. The manager confirmed that, wherever possible, bank staff known to service users and the home are used to cover vacant shifts. During this inspection the home was well staffed, with the manager and three care staff on duty. The record of staff training shows that staff are receiving core training and specific training to help them meet service users’ care needs. The Manager must ensure that details of Criminal Record Bureau checks are available for inspection. This is a repeat requirement. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 40, 41 and 42. The Manager provides clear leadership and has a good understanding of the areas in which the home needs to improve. EVIDENCE: Since the last inspection, a new manager has been appointed. The new manager has made a number of changes and the Inspector felt that standards of care recording in the home have improved. There is a need to ensure that the manager applies for registration with the Commission and also applies for a Criminal Records Bureau Enhanced Disclosure. These applications must be made without further delay. Yarrow has developed a clear quality assurance programme that includes the views of service users and the manager confirmed that this is being implemented. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 17 All of the required policies and procedures are in place and these are reviewed regularly. Standards of record keeping are good. During this visit the Inspector checked care planning records, service users’ medication and finance records and health and safety records. Records are well maintained and up to date. One health and safety issue was noted during this inspection. There is a need to ensure that the record of fire drills contains information about the service users and staff involved and the time it takes to evacuate the building. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 18 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 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 BRACKENBURY ROAD (37) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 3 3 2 x G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 19 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. 2. 3. Standard YA6 YA9 YA34 Regulation 15 13 19 Requirement Timescale for action 30/09/05 4. YA37 9 Care plans must be regularly reviewed and should include clear goals for service users. Risk assessments must be 30/09/05 regularly reviewed. Details of staff CRB checks must 31/08/05 be kept in the home. This is a repeat requirement. Original timescale of 31/03/05 not met. The Manager must apply for 31/08/05 registration with the Commission. He must also apply for a CRB check through the Commission. 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 YA42 Good Practice Recommendations Records of fire drills should contain more detailed information. BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 20 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 BRACKENBURY ROAD (37) G60-G09 S19145 BRACKENBURY ROAD UIV237099 110705 STAGE 4.doc Version 1.40 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!