Inspection on 18/04/05 for Coverdale Road (2)

This inspection was carried out on 18th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coverdale Road (2) 08/05/07

Coverdale Road (2) 25/04/06

Coverdale Road (2) 06/10/05

Coverdale Road (2) 21/10/04

Coverdale Road (2) 05/04/04

Similar services:

Ashlong House

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Edenvale

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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 COVERDALE ROAD 2 Coverdale Road Shepherds Bush London W12 8JL Lead Inspector Tony Announced 18 April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. COVERDALE ROAD Version 1.10 Page 3 SERVICE INFORMATION Name of service Coverdale Road Address 2 Coverdale Road, Shepherds Bush, London W12 8JL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8749 9559 020 7386 6601 London Borough of Hammersmith & Fulham Hannah Cronin Care Home 6 Category(ies) of Learning Disabilities registration, with number of places COVERDALE ROAD Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24 October 2005 Brief Description of the Service: Coverdale Road is a registered care home providing accommodation and personal care for 6 people with a learning disability. At the time of this inspection there were 4 men and 2 women living in the home and no vacancies. The house is close to shops, public transport and other services. Hammersmith and Fulham Social Services Department own the property and manage the service. Service users have single bedrooms and access to spacious communal rooms and a pleasant, paved rear garden. The building is not suitable for wheelchair use, as access is via steps at the front and the kitchen and dining room are on the lower ground floor. Service users attend local day services, while also spending time at home and using community and leisure facilities. COVERDALE ROAD Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on Monday 18th April 2005 from 09:30 – 15:30. The Inspector spoke with service users and staff, checked care records and saw all parts of the home. Six service users, four relatives and two health or social care professionals returned confidential questionnaires and their comments are included in the report. The home provides good standards of care but the standard of accommodation is poor and must be improved. Nine of the fourteen requirements made at the last inspection have been met. Five requirements are repeated in this report. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. COVERDALE ROAD Version 1.10 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection COVERDALE ROAD Version 1.10 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5. Service users’ care needs are well assessed and staff have a good understanding of each person’s support needs. EVIDENCE: The six people living at Coverdale Road have lived together since 1998. The Manager confirmed that the local authority has established procedures for filling vacancies in the home. The procedures include a full care needs assessment, completed by a social worker from the multi-disciplinary Learning Disability Service. The last inspection report required the local authority to provide each person living in the home with a contract / statement of terms and conditions of residence. During this visit the Inspector checked the care plan files of three people living in the home. Each file included a contract that had been signed by the service user, the home’s manager and the local authority’s Reviewing Officer. In one case, an independent advocate had been through the contract with the service user to ensure that they fully understood the contents before signing. Two of the people living in the home have mental health needs. The local authority must apply for a variation of the home’s registration and the Statement of Purpose must be reviewed to reflect these needs. COVERDALE ROAD Version 1.10 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 and 10. The standards of care planning and risk management in the home have improved significantly since the last inspection. EVIDENCE: At the last inspection it was noted that service users’ care plans needed to be reviewed and updated. During this visit the Inspector checked three service users’ care plans. All three plans had been reviewed in January 2005. The reviews involved the service user, their relatives, staff from the home and the Council’s Reviewing Officer. All three plans included a clear assessment of the person’s care needs. The service user’s key worker also produced a report for the review, highlighting significant developments in the person’s life and any changes in their care needs. Staff have worked well to make the plans ‘person-centred’ and each plan included a number of clear goals based on the wishes of the service user. Staff should ensure that background information on the person’s life is recorded as part of the care plan. The home’s standards of risk management are good. All three care plan files included current risk assessments that had been updated in March 2005. Information about service users is securely stored in lockable filing cabinets and information held on the home’s computer is password protected. COVERDALE ROAD Version 1.10 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 16 and 17. Links with the local community are good and service users have a variety of leisure opportunities. EVIDENCE: The three care plans checked during this inspection each included a full weekly programme of activities. Staff who spoke with the Inspector were very aware of the likes, dislikes and interests of each person living in the home. Programmes have been developed to ensure that each person has opportunities to choose activities during the day and evenings and at weekends. Each service user also has one day a week at home when they have 1:1 support from staff to take part in an activity of their choosing. Three people also have full-time places at a local authority day service. Two people living in the home use signs from the Makaton Vocabulary, a communication system for people with a learning disability. The requirement that staff receive Makaton training has not been implemented and is repeated in this report. Service users told the Inspector that they were involved in choosing the weekly menu. Menus provided by the home showed that a variety of nutritious meals are provided. COVERDALE ROAD Version 1.10 Page 10 Six service users returned confidential questionnaires that had been completed with support from staff or other people. All six people said they liked living in Coverdale Road and felt safe. Three people said the home provides suitable activities. Two people said suitable activities were not provided and one person did not comment. Four relatives returned confidential questionnaires. All four people said that they were satisfied with the overall standards of care provided in the home. All said that they are welcomed to visit the home at any time and staff kept them informed of significant matters affecting their relatives. One relative commented ‘I am happy with staff levels generally but (my relative) is a very social person and it would be nice if he could go out in the evening with someone for some adult time (going to the pub for a drink he would love for example) but staff are not available to make this happen. Some of the residents are OK with being in most evenings but (my relative) would really enjoy and benefit from the occasional social time’. Another relative commented ‘I have always been very welcome at Coverdale Road and have been invited to a social evening many times. The staff have always been very nice and (my relative) has lived there for over twenty years’. COVERDALE ROAD Version 1.10 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. The health and personal care needs of people living in the home are well known to staff and individuals are supported to be as independent as possible. EVIDENCE: The three care plans checked by the Inspector included good information about each service user’s health care needs and how these are met in the home. Staff said that service users currently need little physical support with their personal care, but this is provided if required. All six people living in the home are registered with local GP’s and the Inspector saw evidence that dentist and optician referrals are made when required. The home also has good links with the multi-disciplinary Learning Disability Services that includes health care professionals. Two of the three care plans included a recent assessment by a psychologist. Speech and language therapists, physiotherapists and community nurses, support other service users. A local pharmacist provides all prescribed medication. The Inspector checked the Medication Administration Record (MAR) sheets for all six people living in the home. Standards of prescribed medication management have improved since the last inspection. Medication is well recorded and secure storage is provided in the home’s office for all prescribed medication. Two health care professionals returned confidential questionnaires. Both said that staff communicated clearly, worked in partnership and understood service users’ care needs. COVERDALE ROAD Version 1.10 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Complaints are well recorded but there is a need to review the way service users’ personal money is spent. EVIDENCE: The home’s complaints record shows that there have been four formal complaints since the last inspection. Three complaints were from neighbours and one complaint was from a relative. All four complaints were well recorded and investigated. The record included the outcome of each complaint. The Inspector checked the finance records for three people living in the home. All transactions are well recorded and staff obtain receipts for any expenditure of service user’s money. Two issues were discussed with the home’s Manager during this inspection. All six people living in the home choose to eat meals in local pubs, cafes and restaurants, in some cases three or four times each week. This can involve spending a significant percentage of the person’s benefits on food. The National Minimum Standards say that the home must provide service users with three meals each day. The local authority must review the use of personal money to pay for food, but care must be taken to ensure that service users are not prevented from exercising their choice of where to eat. Service users’ also detailed the financial benefits paid to each service user. The local authority must review the benefit entitlement of each person to ensure they are receiving the correct benefits. Two relatives who returned confidential questionnaires said that they were not aware of the home’s complaints procedures. The local authority should make sure that all relatives know about the complaints procedures. COVERDALE ROAD Version 1.10 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30. The standards of decoration and furnishing are poor with little evidence of planned maintenance. The home does not provide a homely or comfortable environment for service users. EVIDENCE: The home is located in a residential area of Shepherds Bush, close to local shops and transport links. The building is not accessible to people with limited mobility as there are steps to the front door and accommodation is arranged over four floors. Each service user has a single bedroom. Communal areas, including lounges, the kitchen, bathrooms and toilets are shared. A major issue arising from this inspection is the need to significantly improve the standards of decoration and furnishings in the home. The local authority’s Accommodation Manager and Facilities Manager came to the home during this inspection, to discuss urgent and longer-term works that are required. Timescales were agreed that would result in an acceptable standard of accommodation being provided by the end of 2005. The local authority must meet these timescales. COVERDALE ROAD Version 1.10 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35. Agency staff are used to cover the majority of staff in the home and there is an urgent need to recruit permanent care staff. The levels of staffing also need to be improved. EVIDENCE: After a period of instability the home now has a permanent Manager and Deputy Manager. Agency staff cover five of the home’s six Residential Support Worker posts, plus an additional 79.5 hours each week for 1:1 support and night staffing. While the Manager uses agency staff who are known to service users, continuity of care cannot be maintained easily and permanent staff must be recruited. The lack of permanent staff also means the home does not meet the requirement to have 50 of care staff qualified to NVQ Level 2. The local authority must ensure that NVQ qualified staff are recruited or agency staff used in the home must have an appropriate NVQ qualification. There is also a need to ensure that a minimum of two staff are on duty at all times. Currently the home is staffed by only one person for 30 of the week. Given the care needs of people living in the home there is a need for a minimum of two staff at all times. The home’s Manager showed the Inspector copies of Criminal Records Bureau checks for all staff working in the home. COVERDALE ROAD Version 1.10 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. The home has a permanent, qualified Manager who has a clear development plan for the service. EVIDENCE: The Manager is completing the NVQ Level 4 Registered Manager’s Award. She was appointed in November 2003 as an acting Manager and was appointed to the permanent post in January 2004. The Manager has successfully applied for registration with the Commission for Social Care Inspection and has been approved as a fit person to manage the home. Formal quality assurance systems are needed to ensure that standards of care are regularly reviewed. These should be based on the views of service users, using independent advocates where necessary. The local authority has developed all of the required policies and procedures and standards of record keeping in the home are good. COVERDALE ROAD Version 1.10 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 2 2 2 2 2 Standard No 11 12 13 14 15 COVERDALE ROAD 2 3 3 3 x Standard No 31 32 33 34 35 36 Score x x 2 2 2 x Version 1.10 Page 17 16 17 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x 3 3 x COVERDALE ROAD Version 1.10 Page 18 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 YA1 Regulation 18 Requirement The local authority must apply for a variation of the home’s registration and the Statement of Purpose must be reviewed to reflect the needs of service users with mental illness. Makaton training must be provided for all staff (timescale of 31/12/04 not met). The local authority must review the use of service users personal money to pay for food. The local authority must review the benefit entitlement of each person to ensure they are receiving the correct benefits. Flooring in the lower ground floor lounge must be replaced (timescale of 31/12/04 not met). Agreed timescales for the replacement of furniture and carpets must be met (timescale of 31/12/04 not met). Broken kitchen cupboards must be repaired or replaced (timescale of 31/12/04 not met). A washing machine with sluice programme must be installed. Permanent staff must be recruited to fill vacancies in the home. Version 1.10 Timescale for action 01/09/05 2. 3. 4. YA11 YA23 YA23 18 20 14 01/09/05 01/09/05 01/09/05 5. 6. YA23 YA26 23 23 01/11/05 01/11/05 7. 8. 9. YA28 YA30 YA33 23 23 18 31/05/05 31/05/05 01/09/05 COVERDALE ROAD Page 19 10. YA33 18 11. 12. YA33 YA39 18 24 The local authority must ensure that NVQ qualified staff are recruited or agency staff used in the home must have an appropriate NVQ qualification. A minimum of two staff must be on duty at all times. Formal quality assurance systems are needed to ensure that standards of care are regularly reviewed (timescale of 31/12/04 not met). 01/09/05 30/06/05 01/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA22 YA24 Good Practice Recommendations Background information should be included in each service users care plan. Relatives should be informed of the homes complaints procedures. Missing lightshades should be replaced. COVERDALE ROAD Version 1.10 Page 20 Commission for Social Care Inspection 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 COVERDALE ROAD Version 1.10 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. 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