Inspection on 26/04/05 for Cavendish Road

This inspection was carried out on 26th April 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 but made no statutory requirements on the home.

Other inspections for this house

Cavendish Road 09/05/07

Cavendish Road 24/04/06

Cavendish Road 31/10/05

Cavendish Road 29/11/04

Cavendish Road 04/06/04

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 Cavendish Road 274 A&B Cavendish Road London SW12 0BS Lead Inspector Davina McLaverty Unannounced 26 April 2005 10.30am th 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. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Cavendish Road Address 274 A&b Cavendish Road London SW12 0BS 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 8675 9957 020 8675 9057 Threshold Housing and Support Ms Carol Hyman (Subject to CSCI approval) Care Home (CRH) 9 - Learning Disability (9) - Physical Disability (2) (E) - Learning Disability - Over 65 (2) (E) - Physical Disabilty - Over 65 (2) Category(ies) of LD registration, with number PD of places LD PD Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29/11/04 & 1/12/04 Brief Description of the Service: Cavendish Road is a registered home for nine adults who have a learning disability, two of whom also have a physical disability. The home itself is two adjoining houses. There are two lounges, two kitchens and two separate laundry rooms. Parking for two cars is available.The property is situated within a ten-minute walk from Balham underground and main line station and high street. The home is owned and managed by Threshold Housing and Support a locally based housing association. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 10.30am concluding at 5.40pm. The inspector met all the current service users. Communication with seven of the service users was not possible, as they were unable to communicate verbally due to their learning disability. The inspector spoke with six staff members as well as the manager and deputy manager of the home. A partial tour of the premises took place and staff and care records were inspected. The manager informed the inspector that the Threshold Housing and Support had merged with another organisation “Open Door” and that the company was now known as “Threshold”. The Commission must be formally notified in writing of this change to allow for a new certificate to be issued. What the service does well: What has improved since the last inspection? What they could do better: The care planning must give clear information on how needs will be met and must be compiled in consultation with service users. Requirements made at the previous inspection must be fully addressed within the given timescales. At the time of the inspection the inspector still found minor shortfalls with several requirements previously made. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 6 Recruitment of permanent staff must be seen as a priority to ensure continuity of care for service users. 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. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 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 Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 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) 1, 2 & 4 The Statement of Purpose provides sufficient information to families and commissioners regarding the home. An appropriate assessment procedure is in place, which enables service users to make decisions about their care. Opportunities are provided for prospective service users and families to visit the home. EVIDENCE: The Statement of Purpose had been updated since the last inspection and provides purchasers and service users with comprehensive information about the home and service provided. The Service User Guides could not be located but the manager maintained that this had also been updated and that a copy would be forwarded to the commission. The manager reported that the organisation is still working on producing a service user guide in a video format. A comprehensive assessment package is in place and the manager was aware of the need to carry out her own assessment as part of the process. No new service users had been admitted since the previous inspection and the home had one vacancy. Assessment reports had been requested from commissioners following the requirement made at the previous inspection, however some were still outstanding. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 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, 9 & 10 There has been an improvement in the updating and recording on care plans and risk assessments however minor shortfalls were noted. Service users where able, are involved in decision making. EVIDENCE: Three service user plans were examined. The plans covered areas such as personal care, daily routine, family contact, leisure activities and health issues, however one of the current plans was not clear when it was due to be reviewed or evaluated. This was discussed with the manager. An evaluation report was not completed and it was not clear how decisions made at service users statutory review, were integrated into the care plan. Daily logs are now only completed on service users who are home all day, for other service users the daily log is completed when something significant occurs. One file did not contain up to date personal details for a service user. The current system failed to clearly evidence how care is being delivered to service users and should be reviewed. Photographs of service users were not seen on their personal files, the manager stated that photographs were on the medication file. The inspector saw this. Staff reported that service users are encouraged to be involved in their care plan and that the home is looking at a more person centred approach to care Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 10 planning. Service users meetings are held at the home, staff are familiar with service users body languages and held the view that several service users understood many questions they were asked. Pictures were being used to help service users make a choice. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 11 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) 14,15,16, &17 The staff team have a good understanding of the service users’ support needs. This is evident from the positive relationships, which have been formed between the staff and service users. Support with activities is offered in such a way as to promote service users individual needs and interest. EVIDENCE: One service user goes out on their own and a risk assessment is in place to try to minimise the risk she poses to herself. All other service users are escorted. Service users are supported to go on holiday and one service user spoke of looking forward to going away. The registered manager stated that six of the service users have some contact with family members and this varied from an occasional telephone calls to weekend stays. Staff reported that they regularly take service users out to the park, pub, and shops or to the local gateway club. They maintained that service users are well known and are part of the local community. A range of television and music equipment was observed in the lounge areas. Some games/activities were also available. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 12 Adequate records are kept of food taken by service users. One service user said that “we have good meals here” and “ I can help myself to drinks and sandwiches”. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 13 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 & 20 The health care needs of service users are met. An improvement in medication documentation was seen. EVIDENCE: Evidence was seen in the care plans examined of input from health care professionals including dentists, opticians and district nurses. Staff in the home can refer service users to the local specialist community and support team for support and advice. Improvements were noted regarding the medication policy and procedures, which now cover all medication procedures. Medication in “House A” was checked by the inspector and found to be satisfactory. The allergy section of the medication administration sheet was completed. Medication was also found to be stored correctly. The inspector was informed that there is a pharmacist available for advice as part of the service offered. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 A complaints procedure is in place and is displayed in the home. Systems for the recording and monitoring of complaints are in place. Organisational policies and procedures are available to protect service users from abuse. EVIDENCE: Two complaint policies are available. One is in a pictorial format. The complaints book and details of one complaint were seen. The complaint had been referred on to head office staff to investigate. The complaint outcome was not recorded. The home users Wandsworth Local Authorities Policy and has organisations guidelines regarding the protection of vulnerable adults which include a whistle blowing policy. The manager stated that staff receive training on these issues as part of their induction as well as have the opportunity to attend a refresher course. Staff spoken to were aware of the action they must take in the event of allegations being made. The service user spoken to was aware of the complaints policy but stated that “I like it here”, “I don’t need to complain about anything”, and “All the staff are nice”. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 & 30 The Standard of the environment within the home is good, providing service users with an attractive and homely place to live. The standard of maintenance of the premises is also good. The home was found to be clean and free from offensive odours on the day of the inspection. EVIDENCE: This is a purpose built home with accommodation over three floors and is served by a passenger lift. The home is divided into two and know as house A and B with each having its own front door. Access however to each house can be gained once inside the home. Each house has its own lounge, kitchen and laundry area. The garden is shared. On the day of the inspection the home was found to be homely, comfortable and generally well maintained with the exception of the garden area which was overgrown and in need of attention. The home has four bathrooms and five toilets. Two service users have ensuite facilities. One service user said that they “liked their bedroom”. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 16 The home was observed to be clean and hygienic and free from offensive odours on the day of the inspection. The requirements made at the previous inspection: - that the ground floor bedroom, in flat A is redecorated and that curtains are re-hung with appropriate hooks /fittings, the manager stated that they would shortly be addressed. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The records seen in the home did not evidence that all the required checks, as detailed in the regulations are carried out before the person is employed. EVIDENCE: Three staff records were seen at this inspection, and were found not to contain all the required information detailed in regulation. Two records lacked any information on the person’s health, no recent photo was evident. Criminal Bureau Records checks were seen on two of the files. There was no information on the checks carried out on agency staff. The manager reported that the home could only use agency staff from agencies approved by Threshold. However there was no record in the home confirming what checks the agency had carried out. Staff records are centralised and the manager reported that not all records are kept in the home, however the home must keep records with dates of all the checks carried out on all staff in order to ensure that service users are not being put at risk. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 18 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, 38 & 42 The Registered Manager is competent and provides clear direction and leadership within the home. Systems are in place for consultation with service users and service users rights and interests are safeguarded by the homes policies and procedures. The health and welfare of service users are promoted within this home. EVIDENCE: The manager has worked in the home since July 2003 initially she was in an acting position. She has been interviewed by the Commission and is currently awaiting the homes new certificate. The manager stated that her qualifications are equivalent to the NVQ Level four, written verification of this is still outstanding. Staff spoken to were positive about the managers leadership, stating that the manager was open with them regarding the operation of the home and that they worked as a team to meet the service users individual needs. Staff meetings take place where information and ideas are shared. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 19 A quality assurance programme is in place. Monthly, regulation 26 visits take place. Records were seen regarding Portable Appliance testing, fire safety tests; premises risk assessment and gas safety. All were found to be in order with the exception of the fire risk assessment, which required updating. Hot water temperatures, fridge and freezer temperatures are checked weekly. A legionella test was satisfactory. A copy of the homes insurance certificate is displayed in the home. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 20 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 2 2 x 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish Road Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 21 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 1 Regulation 5 Requirement The Registered Person must forward a copy of the revised Service User Guide to the Commission. The Registered Persons must ensure that copies of individual core asessments are obtained. Previous date of 28/2/05 not fully met The Registered Persons must ensure that suppot plans are fully completed and are regularly reviewed and updated. Previous date of 28/2/05 not fully met The Registered Person must ensure that the outcome of any complaints is recorded. The Registered Person must ensure that the ground floor bedroom in House A is decorated before a new service user moves in. The Registered Persons must ensure that all curtains have appropriate hooks/fittings to ensure that they hang properly Previous date of the 31/1/05 not met The Registered Persons must ensurethat individual staff record are maintained as per Timescale for action 30/6/05 2. 2 14(1) (2) 30/6/05 3. 6 14(2) & 15 30/6/05 4. 5. 22 26 22 23(2) (d) Immediate 30/6/05 6. 26 23(2) (d) 30/6/05 7. 34 19 1(b) 30/6/05 Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 22 8. 39 24 9. 10. 42 23(4) requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation as to all checks caried out on agency staff. Previous date of 28/2/05 not fully met. The Registered Persons must ensure that the quality assurance framework takes into account the views of family, friends and other stakeholders and that the whole process of quality monitoring is consolidated. Previous date of 31/3/05 not met The Registered Persons must ensure that the fire risk assesment is updated. 30/7/05 30/6/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 28 Good Practice Recommendations The Registered Persons should consider employing a gardener to ensure that the front and back garden areas remain tidy. Cavendish Road G54-G04 S10177 Cavendish Road V223529 260405 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ground Floor 41-47 Hartfield Road London SW19 3RG 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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