Inspection on 31/10/05 for Cavendish Road

This inspection was carried out on 31st October 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cavendish Road 09/05/07

Cavendish Road 24/04/06

Cavendish Road 26/04/05

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 Inspection 31st October 2005 11:00 Cavendish Road DS0000010177.V262541.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 Cavendish Road DS0000010177.V262541.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. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cavendish Road Address 274 A&b Cavendish Road London SW12 0BS 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) 020 8675 9957 020 8675 9057 Threshold Housing & Support Ms Carol Hyman Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2), Physical disability (2), of places Physical disability over 65 years of age (0) Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th April 2005 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 a locally based housing association. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection over 6 hours. The inspector met seven of the current eight service users living in the home. Communication with five of the service users was not possible, as they were unable to communicate verbally due to their learning disability. The inspector spoke with four staff members, the deputy and the temporary manager. A sample of records was examined which included care plans, health and safety, staff records and residents meetings minutes. The communal areas of the house was also seen. What the service does well: What has improved since the last inspection? What they could do better: Further work needs to be done on the care planning system to ensure that each care plan covers the full needs and aspirations of each individual. Care plans must clearly show how the home will meet these needs and wishes. As stated at the last inspection, recruitment and retention of staff must be seen as a priority. All checks detailed in regulation must be carried out before any staff begins employment in the home. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 6 The home must also ensure staff training in areas such as food hygiene, first aid, fire awareness and health and safety are regularly updated. An induction programme must be put in place for all new staff. Staff supervision must take place on a 1 to 1 basis, at least six times a year to ensure that they have the support and direction to carry out their jobs safely and efficiently. Failure to fully address these issues may lead to enforcement action being taken by CSCI. 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 DS0000010177.V262541.R01.S.doc Version 5.0 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 Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 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): EVIDENCE: None of these standards were inspected at this inspection. There had been no new admission to the home since the previous inspection, although the home is currently in the process of assessing a potential resident for a vacancy. One of the two requirements made at the previous inspection had been met outstanding was copies of the individual residents core assessments being obtained. This requirement has been re-stated. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 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 the following standard(s): 6 Further work needs to be carried out on the care plans to ensure that there is a clear plan of care for each resident. The plan should be person centred and fully address resident’s individual needs and aspirations. EVIDENCE: Basic care plans were seen to be in place. The locum manager stated that the staff team had received further input into the homes care planning system and that all residents plans were to be updated. The plans seen did not reflect the full needs of residents or their aspirations. There was also little evidence of other professionals and relatives being involved or consulted which staff said was not the case. Resident meetings were seen to be taking place and staff stated that through their work they are familiar with resident’s body languages and held the view that several service users understood many questions they were asked. The inspector saw evidence of this through observation of staff with residents who are non –verbal. Pictures are also used to help some of the residents make choices e.g. what they would like to eat or do. Cavendish Road DS0000010177.V262541.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): 12,13, 14 & 17 Residents participate in activities of their choice within the home and the community. Residents are encouraged and supported to maintain contact with their family and friends. Dietary needs seem well catered for with consideration being given to cultural needs. EVIDENCE: Six of the eight residents attend a day centre Monday to Friday. The other two are involved in individual activities of their choice. The residents were seen on their return from the day centre and appeared content. As stated earlier the inspector was not able to communicate with five of the residents. One resident spoke of the changes occurring at the day centre and raised some concerns that not as many activities were available there. This was raised with the manager who said she was going to discuss this with the residents social workers as well as visit the day services herself, to get an idea of the changes. Residents, where able are involved in some of the domestic tasks around the home such as looking after their own rooms, setting tables and clearing away after meals. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 11 Staff reported that several residents are supported to see their families and friends. The resident spoken to confirmed this. The menu seen was satisfactory with a choice offered. The resident spoken to said that she found the food to be good although would like to see the resurrection of the Friday take-away which now did not happen as frequently as in the past! Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Arrangements are in place for residents to be offered regular health care checks. EVIDENCE: As stated at the last inspection residents are offered regular health care checks. Evidence of this was seen in the care plans examined where visits had been made to GPs dentists, opticians and district nurses. Staff can refer residents to the local specialist community and support team for support and advice. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 A suitable complaint procedure is in place. Organisational policies and procedures are available to protect residents from abuse. EVIDENCE: A pictorial version of the complaint procedure was seen to be displayed in the home. A resident stated to the inspector that they had nothing to complain about as they enjoyed living at Cavendish Rd and had lived there for over nine years. The complaint book showed that one complaint had been made since the previous inspection. The complaint related to medication not being given, however, on investigation this was found not to be the case. The home had Wandsworth Local Authorities Policy on the Protection of Vulnerable Adults. Threshold also has its own policy and procedure which links into Wandsworth policy. A whistle blowing policy is also available. The deputy manager stated that staff receive training in 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. All eight residents are supported to manage their money. An adequate system is in place which safeguard residents’ money. Copies of receipts are kept and individual residents money is checked and signed as correct at the daily hand over meeting. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 The home was seen to be well maintained and provides a homely environment to the residents. Communal areas are adequate and comfortably furnished. The home was found to be clean and free from offensive odours on the day of the inspection. EVIDENCE: As stated earlier the home is divided into 2 units with their own kitchen, lounge, bathrooms, and laundry rooms on the ground floor. The home was seen to be comfortable and a homely atmosphere was apparent. Pictures of the residents on the walls added to this. The kitchen/dining rooms were seen to be well decorated. Attempts had been made in the bathroom areas to make them homely rather than solely functional. One resident due to his needs had his own chair in the lounge, however, the chair requires cleaning or recovering, as it was dirty in appearance. The deputy manager said that this would be done this weekend when the home was hiring a steam cleaner to clean the hallway carpets in both houses and that the chair would also be cleaned. All residents have their own single bedrooms, which staff reported are personalised to their taste. A resident said that she had everything she Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 15 wanted in her room. This resident said that her privacy is respected in that she can go up to her room when she chooses and said that she often went upstairs to listen to her music. Bedrooms can be locked and those residents that are able have a key. The home was observed to be clean and hygienic and free from offensive odours on the day of the inspection. However, due to a leak from the roof damage had occurred to the Laundry room in House, A which now requires redecorating. The requirements made at the previous inspection: - that the ground floor bedroom, in House A is redecorated had been addressed. Progress had been made regarding getting the curtains re-hung with appropriate hooks /fittings. As this was not completed the requirement has been re-stated. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 16 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, 35 & 36 Adequate staffing levels are in place. The training provided helps in ensuring that a well-informed staff group supports residents, although records must be kept. The recruitment checks seen still did not evidence that all the required checks had been carried out thereby putting residents at risk. Staff supervision needs to be carried out on a regular basis. EVIDENCE: When all residents are home there is a minimum of three staff on duty in addition one resident has one to one support from 4.00pm to 8.00pm on weekdays and all day on Saturday. The manager works 9-5 pm Monday to Friday. At night there is one waking night and one staff asleep but on call. The inspector endeavoured to examine three staff files of new staff members one could not be located and only the CRB check was seen. The other two files varied in information but both did not contain all the required information. This was discussed with the temporary manager and deputy. The requirement made at the previous inspection has been re-stated and must be addressed as a matter of urgency. In addition staff records seen were not up to date and it was not possible to clearly see what courses staff members had been on, or details of their induction. There must be a training plan for each staff member, which Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 17 identifies need. Evidence of core training undertaken e.g. food hygiene, health and safety, manual handing, medication, fire awareness and first aid must be detailed in the plan. None of this was seen in the files examined. Staff meetings should also take place at regular intervals. Four staff were spoken to individually. All were positive about the care delivered and stated that they enjoyed working at Cavendish Rd. All stated that residents were cared for as a ‘family’ and that there is consistent staff effort to ensure that individual residents needs are met. Supervision notes was seen of some staff but they were poorly presented and failed to evidence that regular supervision was taking place. The inspector recommended that a filing system be put in place to evidence staff details, which must include staff training and supervision. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 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 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): 39 & 42 A quality assurance system is in place but this needs to be fully implemented to ensure that the service is meeting the resident’s needs. Staff carry out regular checks to ensure the heath and safety of residents. EVIDENCE: The quality and monitoring system in place must be fully implemented to ensure that the home is meeting its stated needs and objectives. The views of residents, relatives and other stakeholders should be taken into account when carrying out an annual review of the service. Regulation 26 visits must be carried out monthly with copies of the report following these visits being sent to the Commission. A copy of the report must also be available in the home. Records showed that staff make regular checks on the building and equipment in the home. A sample of the records was seen at this visit. Maintenance Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 19 checks were seen to have been carried out on the fire alarm system, fire extinguishers and hot water checks. All were found to be in order. An updated fire risk assessment was seen to be in place. Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 2 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 2 x 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cavendish Road Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000010177.V262541.R01.S.doc Version 5.0 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 Regulation 14(1) (2) Requirement Timescale for action 30/12/05 2. 14(2) & 15 3 4. YA24 & 26 YA24 &YA26 23(2) (d) 23(2) (d) The Registered Persons must ensure that copies of individual core assessments are obtained. Previous date of 28/2/05 & 30/6/05 still not fully met The Registered Persons must 30/12/05 ensure that support plans are fully completed and are regularly reviewed and updated. Previous date of 28/2/05 & 30/6/05 not fully met The laundry room in House A 28/02/05 requires redecorating. The Registered Persons must 30/12/05 ensure that all curtains have appropriate hooks/fittings to ensure that they hang properly Previous date of the 31/1/05 & 30/6/05 not met All staff must have a training and 31/01/06 development plan which evidence training undertaken, including refresher courses. The Registered Persons must 30/12/05 ensure that a record is available regarding staff induction, which reflect the Sector Skills Councils targets. 5 YA 32 &35 18(1) 6 YA 32 & 35 18(1) Cavendish Road DS0000010177.V262541.R01.S.doc Version 5.0 Page 22 7. 19 1(b) 8. 24 The Registered Persons must 30/12/05 ensure that individual staff record are maintained as per requirements of Schedule 2 & 4 of the Care Homes Regulations 2001.This includes written confirmation as to all checks carried out on agency staff. Previous date of 28/2/05 & 30/6/05 not fully met. The Registered Persons must 30/02/06 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 & 30/07/05 not met 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. 2 YA 36 Refer to Standard Good Practice Recommendations The Registered Persons should ensure that 50 of care staff in the home are working towards their NVQ Level 2/3 in care. The Registered Person should ensure that regular staff meetings take place. 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