Inspection on 06/09/06 for Brentside Cottages

This inspection was carried out on 6th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 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 04/01/06

Brentside Cottages 10/08/05

Brentside Cottages 22/02/05

Brentside Cottages 16/07/04

Brentside Cottages 30/10/03

Brentside Cottages 30/07/03

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Edenvale

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Chatsworth Care - Dawson House

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Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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 Ms Jean Bovell Key Unannounced Inspection 6th September 2006 11:30 Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brentside Cottages Address 80 Ruislip Road East Ealing London W13 0AL 0208 991 9668 0208 991 9668 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) 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 DS0000027724.V310636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 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 DS0000027724.V310636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out between 11:30am and 4:30pm on 6th September 2006. One care support worker and one service user were at the home. The Inspector was advised that the Registered Manager was on sick leave, one service user was attending a day centre and that the other was on holiday with relatives. During the course of the inspection the home’s records, policies and documents were viewed, observations were made and a tour of the building was undertaken. The Inspector spoke to two service users and two care support workers. The requirements that were made at the last inspection and all key Standards were examined. The Inspector received appropriate assistance and co-operation from two members of the care support staff team who covered duty on separate shifts at the time of the inspection. What the service does well: The service users appeared relaxed and comfortable and indicated being happily settled at the home. They related in a friendly manner with care support workers who were on duty during the inspection. The healthcare records relating to the service users were detailed and up-todate and reflective of individual physical, emotional and psychiatric health needs being met satisfactorily. Two care support workers expressed satisfaction with level of training they received and were observed being competent in meeting the needs of the service users. Overall the home was found to be clean, hygienic and well maintained. The environment was safe, calm and homely. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 6 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. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to the home. The service users’ guide and statement of purpose are appropriately detailed. Individual needs and aspirations are satisfactorily assessed and prospective service users are invited to the home prior to admission. EVIDENCE: The home’s service users’ guide and statement of purpose were satisfactorily detailed and written/illustrated in a format suitable for meeting the needs of the service users. It was evidenced on service users files that a comprehensive needs led assessment incorporating separate needs and aspirations had been undertaken in relation to each service user prior to admission into the home. Social workers, relatives and medical professionals – where appropriate, participated in the assessment process and prospective service users were invited to the home. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 9 It was indicated that prospective service users received written confirmation that the home would meet specific assessed needs. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 10 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 and 9. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Care plans are being satisfactorily undertaken and service users receive appropriate assistance and/or support with making decisions and being independent. EVIDENCE: The changing personal, social and health care needs of the service users were reflected care plans viewed. Action plans and set goals had been put into place and risk assessments in relation to specific identified activities had been undertaken. It was indicated that care plans and risk assessments were reviewed on a six monthly basis and that relatives, social workers and medical professionals – as required, were invited to review meetings. A care support worker confirmed that the service users required supervision, assistance or support with their everyday routines including being Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 11 independent. Service users were supported in drawing benefit allowances from the bank and during personal shopping trips. They were also encouraged to make decisions regarding clothing, make up/hairstyles, meals and activities. The personal choices of the service users were reflected in their individual bedrooms and a service user was observed making an independent decision regarding and an activity in the community at the time of the inspection. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 12 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 and 17. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Service users receive opportunities for personal development and are able to participate in appropriate activities. Contact with relatives and friends are encouraged and facilitated and the rights of the service users are being respected. Varied and nutritional meals are provided at the home. EVIDENCE: It was indicated on care plans that service users were able to pursue college courses such as art and cooking. The Inspector was informed by a care support worker that service users were supported during visits to temples or cultural events. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 13 The home has its own vehicle and it is used for shared outdoor activities including day trips, meals out and the cinema. Public transport is generally used when service users are supported during separate activities in the community such as personal shopping and meals out. A care support worker reported that annual holidays were arranged by the home but that service users also went on holiday with their respective family members. An open visiting policy was in place and regular family contact was being maintained and included weekend home visits. Care support workers who were on duty during the inspection were observed interacting with service users in a respectful manner and knocked on bedroom doors prior to entering. It was confirmed by a care support worker that service users received prompting or supervision while undertaking various housekeeping tasks such as laying/clearing tables, washing dishes, tidying bedrooms, loading the washing machine and preparing meals. At least one cooked meal is prepared each day and the choices reflected on the menus were varied and wholesome. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 14 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 and 20. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to the home. The service users receive appropriate support with personal care and their health care needs are being met. The home’s policy and procedures on medication are satisfactory. EVIDENCE: The Inspector was informed by a care support worker that personal care tasks were carried out in privacy within bathrooms and/or bedrooms. It was evidenced on separate health care records that GP and dental appointments were arranged when required. Service users were accompanied to hospital appointments and received access to aromatherapy, therapeutic massages and speech/language and drama/movement therapies. Weight charts were appropriately maintained. The home’s medication policy was in place and it was indicated that medication training had been delivered to the members of the care support staff team. The storage, disposal and administration of medicines were satisfactory. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 15 None of the service users were able to administer their own medication at the time of the inspection. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 16 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 and 23. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The service users are being protected from abuse but CSCI contact details within the complaints procedure are inaccurate. EVIDENCE: The home’s complaints procedure was in place but CSCI contact details had not been updated. The complaints book was viewed and no complaints were made to the home following the last inspection. A health and safety poster was on display and there was a copy of the London Borough of Ealing manual on the protection of vulnerable adults was in place. The records indicated that training on the protection of vulnerable adults had been delivered to the members of the care support staff team. The service users were observed being closely monitored and supervised at the time of the inspection. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The home is well maintained and the environment is safe and well maintained. A requirement under Standard 24 at the last inspection in relation to the refurbishment of the kitchen had been complied with. EVIDENCE: The home was bright, adequately ventilated and spacious. It was comfortably furnished and suitable for shared and/or individual activity. The garden was well maintained and accessible to the service users. There were no issues regarding the laundry. Indoor and outdoor redecoration of the home was ongoing at the time of Inspection. The kitchen had been refurbished in compliance with a requirement under Standard 24 at the last inspection. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 18 Overall, the home was found to be clean, hygienic and well maintained. The atmosphere was calm and homely. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 19 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, 35 and 36. Quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. Care support workers are suitably trained and qualified in meeting the needs of the service users. Requirements made under Standards 33 and 36 relating to staffing levels and staff supervision have not been met. EVIDENCE: A care support worker confirmed that two members of the care staff were currently receiving level 2 national vocational training in health and social care. It was reflected on the rota that the Registered Manager, four full time and two part-time permanent care staff were employed at the home. Although the rotas had been completed several weeks in advance, shifts relating to the Registered Manager had not been filled in. It was indicated that there were insufficient numbers staff particularly during the weekend shifts to ensure activities within the community. Apart from visits to relatives, the individual logs were also indicative of service users being at the home on weekends. This suggested that a requirement relating to staffing levels at the last inspection had not been complied with. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 20 The records indicated that staff training delivered included POVA, health and safety, epilepsy awareness, autism, moving and handling, choking and resuscitation and food hygiene. Records relating to staff supervision were not available. The Inspector spoke to two service users and they were unable to confirm that they received regular supervision. This requirement was made at the last inspection and had not been met. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 21 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 and 42. Quality in this outcome area is adequate. This judgement had been made using available evidence including a visit to this service. The home is adequately run but issues in relation to safety and quality assurance are being managed satisfactorily. EVIDENCE: It was indicated on records viewed that the home was being adequately run. Although quality assurance systems were in place, there was no recorded evidence or confirmation by care support workers that self-monitoring exercises had been undertaken. Regular water temperature and fire safety checks and fire drills were not reflected on the related records. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 22 There was documented evidence that environmental risk assessments had been appropriately carried out. Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 X 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 24 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 YA22 Regulation 22(7)(a) Requirement The Registered Person must ensure that the complaints procedure is updated to include the current CSCI contact details. Staffing levels must be kept under review to ensure that the needs of service users are met. (Time-scale of 30/04/06 not met) The Registered Person must ensure that care support staff members are supervised at least six times annually (Timescale of 01/03/06 not met) Timescale for action 30/10/06 2 YA33 18 (1)(a) 30/11/06 3 YA36 18(2) 30/10/06 4 5 YA39 YA42 24(1)(a)(b) The Registered Person must ensure that quality assurance exercises are undertaken. 13(4)(c) The Registered Person must ensure that water temperature and fire safety checks and fire drills are regularly carried out and recorded. 30/03/07 25/09/06 Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 25 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 Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Area 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 Brentside Cottages DS0000027724.V310636.R01.S.doc Version 5.2 Page 27 - 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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