Inspection on 29/11/05 for Brackenbury Road, 37

This inspection was carried out on 29th November 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 5 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 11/07/05

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 Brackenbury Road 37 Brackenbury Road Hammersmith London W6 0BG Lead Inspector Tony Lawrence Unannounced Inspection 29th November 2005 10:00 Brackenbury Road, 37 DS0000019145.V268633.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 Brackenbury Road, 37 DS0000019145.V268633.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. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Brackenbury Road, 37 Address Brackenbury Road 37 Brackenbury Road Hammersmith London W6 0BG 020 8563 2125 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 Mrs Margaret Angeline Anderson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 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 Shepherds 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 DS0000019145.V268633.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 29th November 2005 from 10:00 – 12:15. The Inspector spoke with four people living in the home, the manager, deputy manager and one member of staff. People living in the home are well supported to take part in a wide range of activities and standards of record keeping in the home are good. The standard of accommodation is satisfactory but some repairs are needed. Four requirements and one recommendation made at the last inspection in July 2005 have all been met. 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 DS0000019145.V268633.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 Brackenbury Road, 37 DS0000019145.V268633.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): The key Standard was met at the last inspection in July 2005. EVIDENCE: The home’s manager confirmed that there has been no change to the group of people living Brackenbury Road since the last inspection in July 2005. The Inspector is satisfied that the home has clear policies and procedures for new referrals. These involve joint working with the multi-disciplinary Learning Disability Services to make sure the care needs of any new service users can be met in the home. Brackenbury Road, 37 DS0000019145.V268633.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 and 9. The care needs of service users and any possible risks are well known to staff and are clearly recorded. EVIDENCE: Key Standard 7 was met at the last inspection in July 2005. During this visit, the Inspector checked the care plan files for two people living in the home. The last inspection report included a requirement that care plans must be reviewed and updated regularly. Each file included a Person Centred Plan (PCP) that had been reviewed in September of October 2005. There was good evidence from the Planning Books and minutes of the review meetings that both service users were fully involved in planning their review meetings. Both people were involved in their own review meetings, together with staff from the home, day service staff, relatives, health and social care professionals. Both plans included some clear goals and an action plan that ensures these are met. The home’s manager also confirmed that dates for the three remaining PCP review meetings have been arranged. The last inspection report also included a requirement that risk assessments must be reviewed regularly. During this visit the Inspector checked the risk assessments for all five people living in the home. All risk assessments have Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 9 been reviewed in September or October 2005. They are well written, clearly identifying possible risks to service users and measures that will be taken to minimise risks. Brackenbury Road, 37 DS0000019145.V268633.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): 12 and 13. People living in the home are supported by staff ton take part in a range of activities, in the home and the local community. EVIDENCE: All five key Standards were met at the last inspection in July 2005. During this visit the Inspector spoke to service users and checked care records kept by staff in the home. Two service users were able to tell the Inspector their plans for the day. One person said they were going to the local day service and the second person planned to stay at home to clean their room and do their personal laundry. Two other people living in the home went shopping with staff and one person went to the park, also with staff support. The care records kept in the home show clear evidence that individual service users regularly take part in activities in their local community. Service users told the Inspector they enjoy going to the cinema and there was evidence that one person goes to see a film of their choice at least once a week. People also go ten-pin bowling and swimming and visit local pubs, cafes and restaurants. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 11 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): 19 and 20. The personal and health care needs of service users are well recorded and systems are in place to make sure these can be met in the home. EVIDENCE: All three key Standards were met at the last inspection in July 2005. During this visit the Inspector spoke with the home’s manager and checked the care plan files for two people living in the home. Both files included a current Person Centred Plan that included a review of each person’s health care needs and details of how these would be met in the home. One file also included some very clear evidence of good joint working with the psychologist from the Learning Disability Services to address issues of anger management and challenging behaviour. The pharmacist based at the local Primary Care Centre supplies all prescribed medication for people living in the home. All medication is securely stored in the office. The Inspector checked the medication records for all five people living in the home. The records were well maintained and no errors were seen. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 12 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): 23. The home has clear policies and procedures in place to make sure service users are safe. EVIDENCE: Both key Standards were met at the last inspection in July 2005. The home’s manager told the Inspector that there have been no formal complaints since the last inspection. During this visit the Inspector checked the finance records for two people living in the home. The records show that service users’ personal money is used appropriately and receipts are always obtained for any expenditure. The manager also told the Inspector that the home’s finances, including service users’ monies, had been externally audited earlier this month. Any recommendations from the auditor’s report will be implemented. Since the last inspection there has been one adult protection investigation involving a person living at Brackenbury Road. The Inspector is satisfied that Yarrow and the Learning Disability Service are dealing with this appropriately and the Commission is kept informed of developments. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 13 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, 27 and 28. The home provides a good standard of accommodation but there is a need to make sure that essential repairs are completed without delay. EVIDENCE: Both key Standards were met at the last inspection in July 2005. During this visit the Inspector saw all communal parts of the home and these were all clean and tidy. While the standards of furnishing and decoration are satisfactory, there is a need to ensure that essential repairs are completed as soon as possible. At the time of the last inspection in July 2005 the home’s kitchen was being refurbished. Since then, four new cupboard doors have fallen off and these have not been replaced. Staff said that the doors have been missing for three months. This results in the kitchen having an uncared for look and one service user appeared to be annoyed when showing the Inspector the missing doors. The defects have been reported to the landlord, Notting Hill Housing Trust, but repairs have not yet been carried out. Yarrow must ensure that all cupboard doors are repaired without further delay. Previous inspection reports have also noted that many of the radiator covers in the home are badly corroded. During this visit the inspector noted that these covers have not yet been replaced. This must be done without further delay. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 14 The home’s manager also reported problems with the home’s hot water and heating systems that mean service users have been without hot water and/or heating on a number of recent occasions. These problems have been reported and contractors have visited the home but staff are not confident that the problems will not happen again. In view of the current cold weather, Yarrow must confirm that the home’s hot water and heating systems have been serviced and are working correctly. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 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 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, 34 and 35. The home is well staffed to support service users. EVIDENCE: Key Standards 32 and 35 were met at the last inspection in July 2005. A requirement was made that details of Criminal Record Bureau checks must be kept in the home for inspection. During this visit the Manager showed the inspector the required details that are securely stored on the home’s computer. Three staff were on duty during this visit. The Inspector felt that staff worked well together to make sure that each service user was supported to take part in their planned activities for the day. The Manager also confirmed that two members of staff have completed their National Vocational Qualification (NVQ) Level 2 or 3 qualification training. One person is doing their NVQ Level 2 training and another person has started Level 3. The Deputy Manager is also doing her NVQ Level 4 qualification training. While the home will not meet the target for 50 qualified staff by the target date of 31/12/05, the Inspector was satisfied that this should be met during 2006. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 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 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, 39, 42 and 43. The home is well managed, but more support is needed from senior managers in the organisation to ensure standards are maintained. EVIDENCE: Key Standard 39 was met at the last inspection in July 2005. The home’s manager has applied for registration as a ‘fit person’ to manager the home and this application includes a Criminal Records Bureau check via the Commission. Yarrow must now ensure that the home’s manager is also supported to start the NVQ Level 4 training as soon as possible. The Inspector saw copies of reports written following monthly monitoring visits by senior managers in August, September and October 2005. Reports for visits made in April, May and June 2005 were not available in the home. Yarrow must make sure that monitoring visits take place each month and a written report must be sent to the home and the Commission after each visit. No health and safety concerns were noted during this visit. Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 17 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 X X X X X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brackenbury Road, 37 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 3 2 DS0000019145.V268633.R01.S.doc Version 5.0 Page 18 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 YA24 Regulation 23 Requirement Yarrow must ensure that all broken kitchen cupboard doors are repaired without further delay. Yarrow must confirm that the home’s hot water and heating systems have been serviced and are working correctly. Corroded radiator covers must be replaced. Yarrow must now ensure that the home’s manager is supported to start the NVQ Level 4 training as soon as possible. Yarrow must make sure that monitoring visits take place each month and a written report must be sent to the home and the Commission after each visit. Timescale for action 31/12/05 2. YA24 23 31/12/05 3. 4. YA24 YA37 23 9 31/12/05 31/03/06 5 YA43 26 31/03/06 Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 Page 19 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 Brackenbury Road, 37 DS0000019145.V268633.R01.S.doc Version 5.0 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 DS0000019145.V268633.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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