Inspection on 10/08/05 for Brentside Cottages

This inspection was carried out on 10th August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brentside Cottages 25/09/07

Brentside Cottages 06/09/06

Brentside Cottages 04/01/06

Brentside Cottages 22/02/05

Brentside Cottages 16/07/04

Brentside Cottages 30/10/03

Brentside Cottages 30/07/03

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Townley Road, 2-3

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Brentside Cottages 80 Ruislip Road East Ealing London W13 0AL Lead Inspector Ged Durkin Jean Bovell Unannounced 10 August 2005 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. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Brentside Cottages Address 80 Ruislip Road East, Ealing London W13 0AL 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) 0208 991 9668 0208 991 9668 Ealing Consortium Limited Ms Finola Sullivan Care Home 3 Category(ies) of Learning Disability (0), Mental Disorder, registration, with number excluding learning disability or dementia (0) of places Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22 February 2005 Brief Description of the Service: Brentside Cottages is a residential care home for three adult female service users with learning disabilities and/or mental health issues. It was first registered in 1994 as a small home, under the Registered Homes Act 1984 and 1991 Amendment Act. The Registered Providers are Ealing Consortium. Acton Housing Association owns the property and is responsible for the maintenance. There is a Registered Manager and a team of support workers who provide care personal and practical support to the service users.The home is a detached property, which was converted from two cottages. It is situated on Ruislip Road East adjacent to the swimming pool. There are local shops nearby, and the shopping centres of Greenford and Ealing Broadway can be reached by public transport. The accommodation consists of three single bedrooms, one of which is on the ground floor. There is a lounge and a separate dining room. The office/sleeping in room is on the first floor. There is a shower and toilet, on the ground floor, and a bathroom and toilet on the first floor. The kitchen and the laundry are on the ground floor. There is a patio area with garden furniture and a good size garden to the rear and in front of the home. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 2:25pm and 5:15pm and was conducted by two Inspectors. There was one service user in the home at the start of the inspection and the other two service users came home from day centres. All were spoken with as well as two members of staff and one relative, who was visiting the home at this time. One of the Inspectors spent time with this relative who gave her perspective on the service. A tour of the house and gardens was undertaken as well as examining a selection of documentation. A significant part of the inspection was spent going through the previous inspection reports requirements, the majority of which have been met. One previous requirement around staff records was not inspected because the registered manager was not available to enable access to staff records. What the service does well: What has improved since the last inspection? What they could do better: Attention should be given to enable staff to be able to focus on meeting the needs, (which can be high) of the service users. Presently, there is an expectation that staff have to be responsible for all aspects of the running of the home that includes cleaning, shopping and maintenance of the gardens, (which are large). Staff spoken with on the day of the inspection indicated that such tasks can be time consuming. This has implications for staff being able to carry out external activities especially if staff are working by themselves. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Although the home has not admitted a service user recently the home has an assessment policy and process that is followed. EVIDENCE: Staff spoken with confirmed the last service user to be admitted to the home had been assessed and been gradually introduced to the home, with the support of family and staff. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7, and 9 Service users have an individual care plan that reflects their needs and wishes. As part of their daily living service users are encouraged to make decisions them selves, as appropriate, and take risks as part of an independent life style. EVIDENCE: The Inspectors viewed one service users care plan. It has been formulated on IPP (individual person centred planning) principles and had been subject to a recent review. The care plan consisted of many facets that included health care needs, personal care needs, eating / drinking preferences, emotional and mental health needs and aims and aspirations. Each service user has a key worker who has special responsibility for ensuring that the care plan is implemented. Each service user has an individual log-book and there is a daily record kept by staff. Staff interviewed said that all the service users are able to make their wishes known to staff with regard to day to day activities e.g. what clothes they would like to wear or food they would like to eat, (pictorial menus were on display in the kitchen). The Inspectors looked at risk assessments for service users for activities such as for going out in the community or using kitchen equipment. All were up to date. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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, 15, 16 and 17 Service users take part in appropriate external local activities. All have contact with family and have their rights respected in their daily lives. Healthy eating is encouraged in the home and service users appear to enjoy their food. EVIDENCE: Staff confirmed that all the service users have a number of activities during the week that include attending day centres and college. On days when service users do not attend such activities staff informed the Inspectors that service users are taken out to local amenities such as cinema or local eating places. One service user is taken to access local cultural amenities in nearby Southall. In addition, the home has a seven seater car which is used for taking service users out and is used for day trips. On the day of the inspection one of the service users had been out in the morning and had had lunch in a local fast food restaurant, which she had obviously enjoyed. All the service users have varying degrees of contact with their families which the home facilitate. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 standard(s) 18, 19 and 20. Service users receive personal support according to their need and preference. In addition, the home ensures that service user’s physical and emotional health needs are met appropriately. None of the service users self medicate and the home have appropriate medication policies and procedures. EVIDENCE: Staff informed Inspectors that all the service users require varying degrees of support in receiving personal care. All care is given in accordance with individual care plans. Service users are able to indicate to staff as to personal taste according as to style and grooming. The home is able to ensure that all the service user’s physical and emotional health care needs are met. All service users are registered with a local GP and are able to access community based services as required. The home uses a monitored dosage system which staff administer. Inspectors examined the medical administration sheets for the current month and found that there had been one occasion when medication had been given but had not been signed for by staff. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 standard(s) 22 and 23 There are no ongoing concerns or complaints however staff need more guidance and training about the issue of adult protection. EVIDENCE: Inspectors examined the homes adult protection policy and found it contained an out dated London Borough of Ealing’s adult protection policy. A previous requirement about staff having adult protection training had not been met. In addition, one of the staff interviewed by Inspectors was not aware of the term whistle blowing and Inspectors had to explain what it meant. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 standard(s) 24 and 30 The home is clean, comfortable and domestic and well suited to communal living. The kitchen is need of repair but plans for refurbishment are well advanced. The gardens in the home are large and need a lot of maintaining. EVIDENCE: The home is well maintained and clean. The fabrics and furnishing are all to an acceptable standard. Service user’s bedrooms are comfortable and well personalised. Although there is now some external help in the garden staff are still expected to cut the grass, which because of both front and back gardens size can be time consuming. The front garden was need of cutting. In addition, staff, together with help from the service users are also responsible for keeping the house clean. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 14 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) 31, 33, 35 and 36 The service users benefit from an effective staff team, in spite of the assorted duties they are expected to carry out. Staff are also able to access training and have clear roles and responsibilities and receive regular supervision. EVIDENCE: Staff have been allocated specific roles and responsibilities to ensure that all the tasks needed to ensure the smooth running of the home are undertaken equally. Inspectors were informed that cover for staff annual leave was now better organised particularly for sleep in shifts, which staff said can be very tiring if a service user has had a disturbed night. During the inspection one staff member had been out doing the weekly shop for the home and returned with a lot of shopping for the home. She then went off duty soon after leaving the remaining staff member. The needs of the service users were such that the Inspectors concluded the inspection because the staff member was in process of starting supper for the service users. Staff confirmed that they receive regular formal monthly supervision. Records examined indicated that the last team meeting had taken place in January. Ealing Consortium have a training programme that staff are able to access. Inspectors viewed training records for individual staff which confirmed that staff are receiving training on a number of subjects, which include first aid, fire safety, choking and resuscitation and Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 15 disability awareness. Staff interviewed were enthusiastic about training and understood the importance of it. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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) 39 and 42 Service users through the reviewing process that takes place every six months have their views taken into account. The home still does not have an annual development plan that incorporates a system of reviewing the quality of care. Health and safety requirements from the previous inspection have been met and there are no current issues. EVIDENCE: The previous inspection made a requirement about the need for an annual development plan. The Inspectors saw no evidence of this at this inspection. All requirements regarding health and safety have been met. Records examined indicated that there were regular fire point testing and there had been two fire drills in the last six months. Staff confirmed that all water is thermostatically controlled and radiators are covered. Staff were unable to locate records of water temperature checks but the home’s diary indicated that these were carried on a regular basis. Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Brentside Cottages Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA 23 Regulation 13 (6) 18 (1) (i) 13 (6) 18 (1) (i) 23 (2) (b) 18 (1)(a) 24 Requirement All staff members must be trained in Adult Protection procedures (timescale of 31/5/05 not met) The homes adult protection policy must contain the current cuurent L B Ealing adult protection policy. The kitchen is in a poor state of repair and must be re-furbished. Staffing levels must be kept under review to ensure that the needs of service users are met The home must have an annual development plan that incorporates a system of reviewing the qulaity of care in accordance with regulation 24 of the Care Homes Regulations 2001 (timescale of 30/6/05 not met) Timescale for action 3/10/05 2. YA 23 3/10/05 3. 4. 5. YA 24 YA33 YA 39 7/11/05 7/11/05 3/10/05 6. 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 Good Practice Recommendations G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 19 Brentside Cottages 1. Standard YA 36 The registered person should ensure that there are regular staff meetings Brentside Cottages G61-G10 s 27724 Brentside Cottages v214243 100805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ground Floor 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. 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