Inspection on 21/02/06 for Chapel Lane, 74

This inspection was carried out on 21st February 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chapel Lane, 74 06/06/07

Chapel Lane, 74 03/11/05

Chapel Lane, 74 05/11/04

Chapel Lane, 74 08/04/04

Chapel Lane, 74 23/10/03

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 Chapel Lane, 74 Hillingdon Middlesex UB8 3DS Lead Inspector Mrs Rekha Bhardwa Unannounced Inspection 21st February 2006 09:25 Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chapel Lane, 74 Address Hillingdon Middlesex UB8 3DS 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) 01895 446958 01895 440826 London Borough of Hillingdon Mrs Margaret Anne Howell Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The radiators must have low temperature surfaces by 31 January 2004. Care Homes Regulations 2001. Reg 13(2)(c). Ramps must be fitted to the front door and from the patio door into the garden by 31 March 2004. Care Homes Regulations 2001. Reg 23(2)(d). 3rd November 2005 Date of last inspection Brief Description of the Service: The home provides a service for six people with learning disabilities. The property is owned by Shepherds Bush Housing Association and the care is supplied by London Borough of Hillingdon. The house is a large detached family residence, which has been extended. The house is situated in a quiet residential avenue in Hillingdon that is within easy reach of public transport links to central Uxbridge and other shopping centres in the area. There are a few local shops within walking distance. All of the six bedrooms are single occupancy and have wash hand basins. There is no lift in the home. The ground floor accommodation comprises two bedrooms and all the shared communal facilities. There is a very large lounge with dining area and access to the garden via French doors. The garden is wheelchair accessible and there is a wheelchair accessible shower/toilet on the ground floor as well as a large domestic kitchen, laundry and office. The first floor has four bedrooms, a shower/bathroom and a toilet. The stairs are fitted with support rails. The Registered Manager is supported by three Care Staff and are currently 68.50 permanent hours short per week. These hours are made up by the Local Authority ‘Reserve Team’ and a local employment agency. The home is accessed at the front by ramp and new ramps now give wheelchair access to the rear garden. The home has a minibus used for outings with Service Users contributing to the cost. The home continues to give care to three men and three women. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 3.35hours was spent on the inspection process. The Inspector carried out a tour of the home, inspected service user plans, servicing records, medication records and staff records. The purpose of this inspection was to follow up the requirements and one recommendation from the last inspection, and to view some additional standards. It is recommended that this report be read in conjunction with the last report to gain full inspection information for the home. The Inspector did not meet the service users on the day of the inspection as all the service users were at day care. Prior to the inspection the Registered Manager was sent a pre-inspection questionnaire to complete. Information contained in the pre-inspection questionnaire has been used to inform this inspection. The Registered Manager was present throughout the inspection. The Inspector did not meet any other members of staff. What the service does well: What has improved since the last inspection? What they could do better: Minor shortfalls were identified in relation to the recording of administration of medication. Where medication has been administered to a service user this must be recorded. Service users wishes in relation to death, dying and ageing must also be recorded. This requirement has been restated from the previous inspection. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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): 2 Service users are assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: All the service users living in the home have been at the home for more than four years. There have been no new admissions to the home. The Registered Manager stated that all referrals are received via the Community Team for Learning Disabilities, a needs led assessment would be obtained and the Registered Manager would undertake her own assessment of the prospective service user. If the assessment concluded that the prospective service user be suitable for the home and a vacancy were available they would be encouraged to visit the home, meet other service users, staff and have a meal. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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&7 The health and personal needs of service users had been identified and were being met. Where possible, service users were encouraged to make decisions about their lives. EVIDENCE: One service users care plan was viewed during the course of the inspection. This detailed the service users assessed needs with regard to personal, social and healthcare and how these would be met. There was evidence in the care plan that the service user and their representative had been involved in the formulation of the care plan. The Registered Manager reported that the service user plan is reviewed annually or sooner if the needs of the service user change. Where possible the service user and their representative is invited to the review. Service users are encouraged to make decisions about all aspects of their daily lives within their individual capabilities. At the time of the inspection none of Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 10 the service users were able to manage their own finances. Information on advocacy services was displayed on the service users notice board in the front entrance. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 the following standard(s): 11,15,16 & 17 Service users are enabled to maintain appropriate and fulfilling lifestyles within and outside of the home, thus enhancing their quality of life. EVIDENCE: Care staff within the home enable service users to maintain and develop their social, emotional, communication and independent living skills. This is incorporated into the service users plan. In the service user plan viewed by the Inspector there was recorded evidence of family involvement, this included involvement in the development of the service user plan and the review. Visitors can be seen in the privacy of the service users bedroom or in the lounge area. Staff also support service users to visit any family or friends. All service users have a lockable bedroom door, at the time of the inspection none of the service users had chosen to have a key. Service users can choose where they wish to spend their time, this could be in their bedrooms or with other service users in the communal areas. Small household tasks are undertaken by some service users i.e. polishing, dusting etc. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 12 Since the last inspection a dessert has been added to the menu for the evening meal. Service users are involved in developing the weekly menu, this takes into account any specific dietary needs. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 the following standard(s): 20 & 21 Medications are well managed in the home, thus safeguarding the service users. EVIDENCE: A policy and procedure on the administration of medication was available. The home uses the Boots Monitored Dosage System. Medication was securely stored in an orderly manner. The medication administration record sheets viewed were generally well completed, with the exception of two omissions in signing noted. All staff working in the home have been trained to administer medication. The Registered Manager reported that a person centred planning system was to be introduced into the home. The Statement of Purpose has been updated to reflect that service users who were under 65 years of age when they moved into the home will still be accommodated in the home when they reach 65 years of age. Work is still in progress with service users who have not been able to express their wishes in relation to death and dying, treatments and religious observance. This requirement has been restated from the previous inspection. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 the following standard(s): None EVIDENCE: These standards were assessed at the last inspection and both were met. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26 & 28 The environment is maintained to a high standard and service users individual preferences are met. EVIDENCE: The Inspector undertook a tour of the premises. The home was well maintained, safe, clean and hygienic. Individual bedrooms viewed were personalised and met service users individual needs and preferences. Furnishings were of a good standard throughout. All service users bedrooms have a lockable facility. Communal areas are homely and equipped with TV, music system and video player. Service users can access the rear garden via the lounge, and the garden is welcoming and well maintained. The Inspector noted that several of the bedrooms were very cold in room temperature. The Registered Manager reported that drafts were coming through the windows and that this had been reported to Shepherds Bush Housing Association, who were in the process of arranging a visit to the home. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 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): 32,33 & 34 Staff recruitment and training procedures are robust, safeguarding service users and providing staff with the skills to care effectively for the service users. EVIDENCE: The staff team is well established and all staff members have experience with working with this service user group. There have been no changes to the staffing levels since the last inspection. The Registered Manager stated that staffing levels are kept under review in line with service users dependency levels. The pre-inspection questionnaire detailed that all staff have completed the NVQ level 2 in care and further training is planned for NVQ level 3 in care. One staff employment file was viewed and this contained the information as required by Schedule of the Care Homes Regulations 2001. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 17 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 & 42 The home is well managed, and there are good systems in place for the management of health & safety, thus safeguarding staff, service users and visitors to the home. EVIDENCE: The Registered Manager manages the home effectively and has an open approach to managing her staff. She has completed the Registered Managers Award (NVQ level 4 in management). The pre-inspection questionnaire, completed by the Registered Manager, detailed the maintenance and servicing of equipment and systems in the home. Servicing records were viewed at random and were found to be well maintained and up to date. Individual and generic risk assessments are in place for safe working practices. Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 18 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 3 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x x x LIFESTYLES Standard No Score 11 3 12 x 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 2 3 x x x x 3 x Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 19 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 YA20 Regulation 13(2) Requirement Timescale for action 20/03/06 2 YA21 The Registered Manager must ensure that all medicines administered are recorded on the Medication Administration Record. 12(1)(b)(2) The home must obtain (3) information regarding the Service Users wishes in connection with medical treatments, arrangements at the time of death, religious observance and wills for those Service Users for whom no information has already been sought (previous timescale of 06/01/06 not met) 30/04/06 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 Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection West London Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Chapel Lane, 74 DS0000032581.V278125.R01.S.doc Version 5.1 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!