Inspection on 04/09/06 for Charleville

This inspection was carried out on 4th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Charleville 01/12/08

Charleville 20/02/07

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 Unannounced Inspection 4 September 2006 10:30 th Charleville DS0000019151.V305886.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.V305886.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.V305886.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.V305886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 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.V305886.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 6 ¾ hours on the 4th September 2006. The inspector met and spoke to service users, staff and the Manager. All service users completed questionnaires prior to the inspection and the inspector received comments cards from relatives/visitors and professionals. Service users’ personal files and other records including medication records, complaints/incidents records and health and safety documentation were seen. What the service does well: What has improved since the last inspection? What they could do better: A total of eight requirements have been set following this key inspection. Four of the eight requirements related to the protection of the service users from abuse. Steps must be urgently taken to improve the systems for protecting vulnerable adults in the home and to ensure that allegations are referred to the appropriate adult protection teams as per the multi-agency policy. CSCI must be informed of all allegations of abuse and any incident, which falls under regulation 37. Requirements were also made to ensure that the Quality assurance system is improved and to ensure support plans are kept up-to-date. Charleville DS0000019151.V305886.R01.S.doc Version 5.2 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. Charleville DS0000019151.V305886.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.V305886.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 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 the needs of service user. Each service user has a written contract of terms and conditions with the home. EVIDENCE: The file of the most recently admitted service user was seen during the inspection. A copy of the service user’s needs assessment and referral documentation was on file. The Manager confirmed that it is the home’s policy to ensure that a copy of the needs assessment is obtained prior to service users being admitted into the unit to ensure that the placement is suitable. The care of three service users was tracked during the inspection and their files were checked. Each service user had a written contract of terms and conditions on their files, which had been signed and dated by service users as confirmation that they are aware of their rights and responsibilities. Charleville DS0000019151.V305886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ needs are outlined in their care plan and there was evidence that service users are involved in the care planning process. Risk assessments and risk management plans were in place for service users. EVIDENCE: The personal files of 3 service users was checked and their care was tracked during the inspection. Each service user had a support plan in place that outlined their personal, health care and social care needs. The support plans also identified service users’ strengths and outlined future move on/resettlement plans. Two of the three care plans were recently reviewed and updated but one of the support profiles is in need of updating as this was last updated in January 2006 and should be reviewed 6 monthly or more regularly if their needs change. The care planning process involved the service users and service users had signed their care plan in agreement with its content. The home operates a key working system of support for service users, which promotes continuation of care. Records of two weekly key working sessions Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 10 were also on file reflecting how the service users are working towards the goals set within the support plans. Daily contact notes are also maintained. Risk assessments were in place and the information was clear and risk management plans were in place. The risk assessments included general health and safety issues and risk factors for each service user. The assessments covered daily life in the home and in the local community. Charleville DS0000019151.V305886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity to take part in a range of activities and access drop-in centres and self-help groups. Service users are supported to develop their independent living skills. EVIDENCE: Activity plans were in place for all three service users. Service users commented in the questionnaires “activities include coffee mornings, BBQ’s, outings and gardening project. “I do attend gardening and Art & Craft but not health eating as I did not know about it. “quite pleased to participate in all activities. I like gardening best”. Four service users out of eight who commented on activities in the questionnaires commented that there are always activities arranged by the home that they can take part in. Service users’ cultural interests are also addressed within the care plans. There was evidence on file that staff are supporting service users to find employment where this has been identified as a personal goal. There is a visiting policy; procedure and visitors book in place and there was evidence on file that staff are supporting service users to maintain contact with family and friends. Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 12 A residents’ meeting took place on the day of the inspection, and service users were given the opportunity to discuss their forthcoming holiday. Each service user has their time slot in the kitchen to prepare their meals during the week and have staff support if required. Service users commented “we cook independently, but on Sunday the staff cook roast and I enjoy that”. Service users are also shopping for themselves; a member of staff will accompany them if requested. Charleville DS0000019151.V305886.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 at least once during a 12 month period. 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 given the opportunity to retain and administer their medication when assessed as competent to do so. EVIDENCE: Service users’ needs with regards to personal care and health care are outlined in their support plan. Pre-inspection information specifies that all service users have a GP. Service users’ comments within questionnaires about the health care support included the following, “I do receive support to go to the doctor surgery and assisted in registering with GP. “I am pleased with medical support”. “I have a first aider at the house and a GP.” Social worker/Care manager commented “the key worker for my client has a clear understanding of his needs. She has a good working relationship with the client” The medication records were seen during the inspection. There is a staged selfadministration process in place in the home, based on the needs of the service users and their ability to self-administer. Each service user has a secure storage area in their room to keep their medication. The Manager confirmed Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 14 that medication arrives in blister packs, which contain the necessary medication for that time period. Charleville DS0000019151.V305886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is poor. 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 are weak and the multi-agency policy was seen not have been followed. Staff need training in the protection of vulnerable adults and become familiar with the local multi-agency policy. EVIDENCE: There is a complaints policy available for service users to view. Service users commented on the whole that they are aware of how to complain if they are not happy with aspects of the service provided. A service user commented that complaints usually “get sorted out in house, if not I can go to the top”. It was noted that complaints can also be addressed at monthly residents’ meetings and service users have the opportunity to discuss issues with their key worker when they meet formally every two weeks. The home has received five complaints within the last twelve months, which have been investigated. The inspector viewed the complaints records and noted that three complaints fell under the Protection of Vulnerable Adults policy. One complaint was investigated by the police and care team and found not substantiated. The CSCI records indicated that it had not received documentation regarding this allegation. Following the inspection, a representative from London Cyrenians said that the documentation was forwarded to the CSCI. The other two complaints related to allegations of verbal abuse made about staff members. Although these allegations had been investigated by the Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 16 Manager, they had not been referred to the local adult protection team as per the agreed multi-agency policy and the CSCI was not informed. There is an urgent need to ensure that all allegations of abuse are reported without delay as per the local multi-agency policy and the regulations. Alongside these allegations some comments made within comment cards included “staff are not very mannered” and “some staff do not help when it is needed”. When asked if the staff listen and act on what they say, two of the nine service users commented no. All staff must receive training in the protection of vulnerable adults and become familiar with the content of the multi-agency policies for the protection of vulnerable adults. The finances of 3 of the service users were checked by the inspector, all records were accurate and up to date. Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. 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 area located in the basement. There have been some changes noted to the premises since the last inspection. The first floor, front and back rooms; second floor left room have been fitted with laminated wood flooring. Laminate wood flooring has also been fitted to the lounge, quiet areas and conservatory area. All beds and mattresses have been changed. The home is currently without a regular cleaner but staff are working hard to clean the home and maintain adequate levels of cleanliness. The Manager discussed the ongoing difficulty the home is experiencing in filling the cleaner’s post. The home would benefit from a cleaner as soon as practicably possible to enable staff to spend more time supporting service users. Charleville DS0000019151.V305886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 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 a high percentage of staff are qualified to NVQ level 2 or above. Staff are supervised regularly. EVIDENCE: Staffing rotas indicate that there is a minimum of two support workers on duty during the day with one staff member sleeping in at the project during the night. The staff member on the sleep over shift was aware of the procedures for contacting support if needed in an emergency. Service users commented that “staff listen to me and are very helpful when I am not feeling well” and “I’m pleased with the care I receive from LCH staff” The personnel files of two staff members were checked during the inspection. Confirmation of a satisfactory CRB enhanced check was on file for both staff. All recruitment practices are carried out by the Human Resources team based at London Cyrenians head office. Vacant posts are externally advertised in national and local newspapers. All applicants are required to complete an application form, to attend an interview and two references are obtained. All new staff are required to attend a four day induction training, which is in line with the skills for care induction programme The home has the input of a training co-ordinator who is based at the London Cyrenians head office who is Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 19 responsible for organising and sourcing training for staff. Pre-inspection information indicated that 80 of the staff team are qualified to NVQ level 2 or above. The inspector noted that staff are in need of training in the Protection of Vulnerable Adults to become familiar with the local multi-agency policy for the protection of vulnerable adults. The inspector noted from the staff files that staff meet formally with their manager for supervision and training needs are identified during this time. Charleville DS0000019151.V305886.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and the competency to run the home. Quality assurance systems are in place but some further work is needed in this area. The health and safety of service users is protected as far as possible but there is some work needed to meet the requirements of the legionela tests. EVIDENCE: The home has an experienced registered manager in post. He has obtained the NVQ Registered Manager’s award and is looking into enrolling on the NVQ assessors award and he keeps himself updated by undertaking periodic training. The inspector found the Manager to be open, approachable and helpful throughout the inspection process. Quality assurance systems in the home include two weekly key working sessions and residents’ meetings where service user can air any concerns. Person in control visits are undertaken monthly and involve service users. Currently these visits are announced. Steps must be taken to ensure that these visits are undertaken unannounced and that copies of the report is Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 21 forwarded to the local office of the CSCI as per the regulations. The home has devised a service user satisfaction survey but steps must be taken to reintroduce this survey and the results must be published and made available to service users, their representatives and the CSCI. Where improvements are needed, an improvement/action plan should be put in place and reviewed on a regular basis. There is an annual development plan in place that staff can contribute to. Health and safety documentation is well maintained with evidence that weekly fire alarm checks take place and safety certificates in place. The home has an up-to-date fire risk assessment in place and the health and safety risk assessment has been very recently updated. The Manager has been working to meet the requirements set regarding the recommendation following the Legionella check and this requirement has been partially met, except for the need to fit in thermostatic mixer valves. Work has been scheduled to take place. The Manager is asked to report to the CSCI of their progress. Charleville DS0000019151.V305886.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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 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 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 15 [2] Timescale for action The Manager must ensure that 01/11/06 support plans are regularly reviewed to reflect any change in needs. The Manager must ensure that 25/09/06 all incidents falling under regulation 37 are reported to the CSCI without delay. The Manager must ensure that 25/09/06 all allegations of abuse are immediately reported as per the multi-agency policy and procedures for the protection of vulnerable adults. The incidents identified on the 25/09/06 day of the inspection and referred to within the body of this report, must be reported to the relevant Adult Protection Team. The Manager must also ensure that the CSCI is formally notified in writing of the details relating to the incident and the outcome of the referral. The Manager must ensure that 01/01/07 all staff receive training on the protection of vulnerable adults and ensure that they are familiar with the content of the multiagency policy for the protection DS0000019151.V305886.R01.S.doc Version 5.2 Page 24 Requirement 2 YA23 37 3 YA23 13 [6] 37 4 YA23 13 [6] 22 5 YA23 13 [6] Charleville of vulnerable adults. 6 YA39 24 The Quality Assurance system must include service users and their representatives’ views and the quality of care must be regularly and formally reviewed and a system must be in place for improving the quality of care. A report must be produced and be made available for service users, their representatives and the CSCI Steps must be taken to ensure that visits on behalf of the registered provider are undertaken unannounced as per the regulations and that copies of the report is forwarded to the local office of the CSCI The Manager to ensure that recommendations set after the legionella check take place. The Manager must forward a report outlining the home’s progress for meeting this requirement. This requirement is partially met 01/01/07 7 YA39 26 30/10/06 8 YA42 12 30/10/06 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 Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Charleville DS0000019151.V305886.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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