Inspection on 20/02/07 for Charleville

This inspection was carried out on 20th February 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charleville 01/12/08

Charleville 04/09/06

Charleville 09/11/05

Charleville 02/11/04

Charleville 05/05/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Charleville 40 Charleville Road West Kensington London W14 9JH Lead Inspector Ffion Simmons Key Unannounced Inspection 20th February 2007 10:15 Charleville DS0000019151.V330253.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 Charleville DS0000019151.V330253.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. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charleville Address 40 Charleville Road West Kensington London W14 9JH 020 7385 6711 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) London Cyrenians Housing Limited Dan Oliver Appiah Care Home 9 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9) of places Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2006 Brief Description of the Service: Charleville Road is a registered home for nine people of either gender with mental health support needs. The proprietors are London Cyrenians Housing Limited. The home is a terraced Victorian mansion block that has been converted with nine bedrooms six with en-suite bathrooms with another three bathrooms for general use. There is a staff sleep over room that also has a bathroom attached for staff use. The home is in West Kensington that is close to local shops, amenities and transport links. The fee for the service is £493.05 per week. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection took place over 5 ¾ hours on the 20/02/07. This was the home’s second key inspection for the inspection year 2006/2007. The inspector spent time talking to the Manager, staff and service users and a range of documentation was checked which included service users’ files. Service users were given the opportunity to provide feedback about the service during the inspection and also through the completion of satisfaction questionnaires. What the service does well: What has improved since the last inspection? Since the last inspection, steps have been taken to ensure that service users’ support plans are up to date. Communication with the CSCI and the Local Authority protection team has improved with incidents falling under regulation 37 being reported to the CSCI. The incidents identified at the last inspection have been reported to the protection team as per the requirements of the last inspection. Staff have received training in the protection of vulnerable adults and a copy of the local multi-agency policy for the protection of vulnerable adults has been obtained. The person in control visits are unannounced as per the regulations and copies of the report relating to this visit is now forwarded to the local office of the CSCI. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Charleville DS0000019151.V330253.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 Charleville DS0000019151.V330253.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to being admitted to the home to assess the suitability of the service for meeting their needs. EVIDENCE: There have been no new admissions to the home since the last key inspection in September 2006. The home’s admission policy requires staff to ensure that they obtain a copy of the service users’ needs assessment prior to service users being admitted into the home. This is to ensure that the placement is suitable and can meet the needs of the service users. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined in their care plan and service users are involved in the care planning process. Risk assessments and risk management plans were in place for service users. EVIDENCE: The care of three service users was tracked during the inspection and their personal files were checked. Each service user had a support plan on their files, which outlined their personal, health care and social care needs. The support plans also identified service users’ strengths and outlined future move on/resettlement plans. The care plans showed that service users had been involved in the care planning and review process. All three support plans seen during the inspection had been recently reviewed and were up-to-date. Risk assessments were in place for each of the three service users tracked, and the information was clear. Risk management plans were in place. The risk assessments included general health and safety issues and risk factors for each service user including an individual fire risk assessment. Service users commented that they were able to make decisions and are able to do what they want to do during the day, evening and week-end. Residents’ meetings take place monthly, where service users are encouraged to Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 10 contribute to decision-making, including deciding on the décor of the communal areas. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have opportunities for personal development and to be part of the local community. Service users are supported to maintain links with their family and friends. EVIDENCE: Service users receive support from the staff team, in particular from their key worker, to develop their life skills. Support is given by staff to enable service users to develop their cooking skills, budgeting skills, personal care and cleaning. There was evidence that staff are supporting service users to find employment where this has been identified as a personal goal. Service users’ preferences with regard to activities are outlined in their support plans and each had an activity plan on their file. In-house activities include arts and crafts, healthy eating sessions, gardening club, coffee mornings and newspaper discussions. Service users are given the opportunity to have Saturday outings for meals out and are given the opportunity for monthly outings for example to the cinema and other locations of interest in London. Six of the nine service users spent five days in Brighton in the Autumn, which service users said they enjoyed. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 12 Evidence was seen on the files of the service users tracked, that they are supported to maintain links with their family and friends where appropriate and as outlined in their care plans. There is a visiting policy; procedure and visitors book in place. During the inspection, service users were observed to have the freedom to leave the home as they choose to go for example to the bank and out shopping. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and personal care needs are identified and outlined within individual support plans. Service users are encouraged to be as independent as possible with regard to medication management. EVIDENCE: Service users’ needs and preferences with regard to personal care are outlined in their individual support plans. Each service user has a key worker with whom they regularly meet. Detailed records were in place outlining the progress made in meeting the goals set within the care plan. Pre-inspection information indicates that all service users have a GP and that service users benefit from the input of the Community Psychiatric Nurses. The Manager told the inspector that referrals have been made to the Occupational Therapist for an assessment of service users’ needs for specialist aids and equipments. The home’s medication arrives in blister packs and each service user has a secure storage area in their room to keep their medication. The home operates a staged self-administration programme, where service users’ ability to self-administer is assessed. Service users are encouraged to be as independent as possible and monitoring systems are in place. Weekly checks Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 14 of the MAR sheets are undertaken. The medication records were seen during the inspection and no issues were identified. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are aware of the home’s complaints policy and are given opportunities to raise issues of concern. Links with external agencies such as the CSCI and adult protection teams have improved and all staff have received training in the protection of vulnerable adults from abuse. EVIDENCE: The home has a complaints policy in place. Service users who provided feedback on the service commented that they know who to speak to if they are not happy with their care and how to make a complaint. The complaints file was checked during the inspection and the inspector noted that there have been no complaints made about the service since the last inspection. Monthly residents’ meetings are held providing service users with the opportunity to comment about aspects of the running of the home. Since the last inspection, all staff have received training in the protection of vulnerable adults from abuse, which included information on how to refer concerns in line with the local multi-agency policy. The home has an electronic copy of the local multi agency policy for the protection of vulnerable adults. Staff have also attended training briefing on the requirements of the Mental Capacity Act. The accident/incident book was checked during the inspection. There were no further incidents/allegations recorded. The inspector noted that there were leaflets and articles placed on notice boards around the house, outlining what to do in the event of someone becoming aware or suspect that someone is being abused. Contact numbers of the protection team of the local authority were also on display. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable home, which is kept clean and hygienic. EVIDENCE: The home is situated in a terraced Victorian mansion block in the West Kensington area, within easy access to local shops, amenities and transport links. Each service user has their own bedroom and the home is set out over a number of floors with the kitchen and lounge areas located in the basement. Due to the home’s physical layout, the home is not suitable for service users who have a physical disability. Since the last inspection, the rooms of four service users have been redecorated and a new carpet has been fitted in one of the bedrooms. The landing areas on the first and second floor have been fitted with laminate flooring and the windows in the home have been measured in preparation for new curtains. Information from the pre-inspection information indicated that all showers have been replaced and fitted with thermostatic valves. All hand basins have been fitted with thermostatic mixing valves as per the Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 17 requirements of the legionella test. Communal bath and shower areas have also been fitted with thermostatic mixer valves. Since the last inspection, a cleaner has been employed for two days per week. A service user told the inspector that the cleaner does a good job at keeping the house clean. Other positive comments were received from a service user within the survey, which included “cleaner in the project is a nice person. Does her job well in relation to ensuring that the home looks clean and fresh.” The inspector viewed the communal areas and found the home to be clean. Service users in their comment card said that the home is either always or usually fresh and clean. A separate laundry area is situated on the lower ground floor, which is equipped with a washing machine and dryer. Service users have their allocated days for using the laundry facilities. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment policy and procedure is robust. Induction training is arranged for new staff and all staff are qualified to NVQ level 2 or above. EVIDENCE: There is a minimum of two staff on duty during the day, and staff sleep over in the project at night. Staff spoken with were aware of the on-call arrangements and for seeking assistance at night in an emergency. There are two vacant support worker posts currently within the staff team. These vacant posts have been advertised and steps are currently underway to short list suitable applicants. The vacant posts are currently being filled by locum workers, employed the London Cyrenians Housing Limited. No agency workers are employed in the home. There have been no changes in the home’s recruitment procedures. All recruitment practices are carried out by the Human Resources team based at London Cyrenians head office. All applicants are required to complete an application form, to attend an interview and two references and criminal records checks are obtained. New employees who work either as locum support workers or permanent staff in the project are required to attend induction training. Local induction training is given to staff. Staff spoken with during the inspection confirmed that they Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 19 had attended induction training and that clear guidelines were provided during the training, outlining their responsibilities when supporting service users. The home has the input of a training co-ordinator who is based at the London Cyrenians head office who is responsible for organising and sourcing training for staff, including arranging updates in mandatory training. Service users commented that “staff here are good”. When asked if staff treat service users well, four service users commented that staff always treat them well, two commented that they usually treat them well and one commented that sometimes staff treated them well. The inspector observed staff respecting service users and providing a good level of support during the inspection. Staff demonstrated a very clear awareness of the needs of service users and responded quickly when a service user was unwell during the day. The pre inspection information outlined that 100 of the care staff are qualified with NVQ level 2 or above. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a qualified and experienced Manager. Quality assurance systems are in place but improvements could be made in this area. EVIDENCE: The home is well run by an experienced registered manager. He has obtained the NVQ Registered Manager’s award and is currently completing the NVQ assessor award course. The Manager attends periodic training to keep himself updated. The Manager was very accommodating, approachable and helpful throughout the inspection process and was very receptive to the inspector’s feedback. The Manager confirmed that since the last inspection, the person in control visits are unannounced as per the requirements and copies of the reports are now forwarded to the local office of the CSCI. Service users are involved in these quality visits. Since the last inspection, the home has created a tenant satisfaction survey to ask service users on a monthly basis how often they see their key worker; if they are satisfied with their care plan and if they would like any changes. The results of these were given to the inspector. A discussion Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 21 took place during the inspection of the benefits of developing a more detailed service user survey, so that service users can comment on all aspects of their care and home environment. The option of enabling service users to feedback anonymously was also discussed. The Manager agreed that a more detailed survey would be designed. The results should be published and made available to service users, their representatives and the CSCI. During the inspection, the inspector was given a copy of the home’s service audit report, which was compiled in July 2006. The report highlighted the project’s strengths and areas for development. The health and safety documentation was checked during the inspection. There was evidence that weekly fire alarm checks take place and quarterly fire drills are performed, showing a prompt response from service users. Specialist equipment is fitted in the room of a service user who has a hearing impairment. The Manager confirmed that this specialist equipment is tested weekly when the fire alarm is tested. Service users have an individual fire risk assessment in place and there is a valid fire risk assessment in place for the building. An immediate requirement notice was issued on the day of the inspection, to remove the wedge that was obstructing the closure of the fire door of the non-smoking lounge. The annual testing of the homes’ portable appliance equipment took place on the day of the inspection. Thermostatic mixer valves have been fitted as per the recommendations of the legionella check. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 22 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 3 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 X 34 3 35 3 36 X 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 23 No 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 YA42 Regulation 23 [4] Requirement The Manager must ensure at all times that fire doors are not obstructed, and that wedges are immediately removed. Immediate requirement. Timescale for action 20/02/07 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 YA39 Good Practice Recommendations A more detailed service user survey should be designed so that service users can comment on all aspects of their care and home environment. Ways of enabling service users to feedback anonymously should also be considered. A report based on the service users’ views should be generated. Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Charleville DS0000019151.V330253.R01.S.doc Version 5.2 Page 25 - 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!