Inspection on 25/04/06 for Coverdale Road (2)

This inspection was carried out on 25th April 2006.

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 3 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) 06/10/05

Coverdale Road (2) 18/04/05

Coverdale Road (2) 21/10/04

Coverdale Road (2) 05/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 2 Coverdale Road 2 Coverdale Road Shepherds Bush London W12 8JL Lead Inspector Tony Lawrence Unannounced Inspection 25th April 2006 09:00 2 Coverdale Road DS0000035470.V289250.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 2 Coverdale Road DS0000035470.V289250.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. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 2 Coverdale Road Address 2 Coverdale Road Shepherds Bush London W12 8JL 020 8749 9559 020 7386 6601 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 Borough of Hammersmith and Fulham Miss Hannah Cronin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th 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, although the Department is consulting on plans to transfer the service to another provider. 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. People living in the home attend local day services, while also spending time at home and using community facilities, supported by care staff. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 25th April 2005. The inspector spent five hours in the home talking with service users, the manager and staff. The care of two people living in the home was tracked and the Inspector also checked all parts of the building and care records kept in the home. The home provides good standards of care and accommodation and is well staffed to support service users. Six requirements and one recommendation made at the last inspection have been met. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 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 the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear referral and admission policies and procedures are in place, but the local authority does need to introduce contracts for service users. EVIDENCE: The six people living at Coverdale Road have lived together for a number of years and the Manager confirmed that there are no current plans to move people on from the home. The home has good links with the local multidisciplinary Learning Disability Team and the manager confirmed that all referrals would come from the Team. The home has developed clear eligibility criteria to make sure that the care needs of people referred can be met in the home. The Inspector checked the care plan files of two people living in the home and both files included a recent assessment of the person’s care needs. The two files checked did include a Service User’s Guide and this contains brief details of the service provided in the home. There is a need for the local authority to produce a contract or statement of terms and conditions that covers all of the areas detailed in Standard 5. This will make sure that service users and their relatives / representatives are fully informed of the levels of care and support they can expect in the home. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 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 the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person living in the home has a current care plan that reflects his or her needs and aspirations. EVIDENCE: During this unannounced visit, the Inspector checked the care plan files of two people living in the home. The home has a system of Person Centred Plans. These are in place for both service users and have been reviewed recently. The Plans clearly record what each person wants to do and how they will be supported to achieve this. Examples include going on holiday, going swimming regularly and going to a football match. In addition to daily log books, each service user’s key worker completes a monthly summary of the care received by the person and this includes information about activities, outings, holidays, day services and leisure opportunities. The Inspector feels that summaries are well completed by staff and provide a clear overview of each person’s daily life in the home. During this visit the Inspector saw some good examples of staff interaction with people living in the home. Service users were supported to make choices about what they wanted to eat and drink for breakfast, what they wanted for 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 9 their packed lunches and what they wanted to wear. At all times staff were patient and aware of individual’s communication skills, always using signs from the Makaton Vocabulary when necessary. Service users were also given support to make real choices – for example, one service user was offered the jars of jam, peanut butter and marmalade and encouraged to choose what she wanted to spread on her toast. The care plans are underpinned by a system of risk assessments that make sure individuals are supported to be as independent as possible. Risk assessments clearly show where service users need additional support to minimise risks and include clear guidelines for staff. Staff on duty during this visit were also aware of the main risk areas for each person and how these will be managed. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to take part in a range of appropriate activities. EVIDENCE: During this visit the Inspector saw five of the six people living in the home. The sixth service user had already left to walk to the local authority’s day service before the Inspector arrived. One person said that they enjoyed the activities provided by the home and the day service. During the inspection staff supported all six people to make use of community activities and facilities. Three people went to a dance class, two people went to the day service and the sixth person went shopping with staff and had lunch out. The two care plans reviewed by the Inspector and the monthly care summaries written by individual’s key workers showed that each person living in the home is supported regularly to take part in activities of their choice. These included trips to the cinema, dance, reflexology and aromatherapy sessions and meals out. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 11 The review of two care plan files showed that service users’ relatives, friends and representatives are kept informed of significant issues and aspects of the person’s care, where this has been agreed as part of the plan. Service users’ relatives / representatives are routinely involved in care plan reviews and their views are clearly recorded. Summaries of care and log books also showed that relatives visit the home and staff support service users to keep in touch with significant people by letter or phone. The local authority has also ensured that relatives have been kept fully informed of plans to transfer the service to another provider and consultation meetings have been held. The rights and responsibilities of people living in the home are outlined in the Service Users’ Guide and people living in the home are registered to vote in elections. Menus provided by the Manager before this inspection showed that a variety of nutritious meals are provided. One service user told the Inspector that they were involved in planning the weekly menu. Service users can eat meals in the dining room or kitchen and both areas provide comfortable spaces for eating. The Inspector saw staff supporting three people to have breakfast. People were offered a choice of cereals, toast with various spreads and a choice of hot and cold drinks. Service users were supported individually by staff who worked well together to make the meal time a pleasant and unhurried occasion. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported well by staff that understand their personal and health care needs. EVIDENCE: The two care plans reviewed by the Inspector included details of each person’s personal and health care needs and how these will be met in the home. The home has good links with the multi-disciplinary Learning Disability Team and the Inspector was satisfied that appropriate referrals are made to clinicians for assessment and support, when necessary. Details of all health appointments are well recorded on the two care plans reviewed during this visit. The home uses a Monitored Dosage System for all prescribed medication. All medication is securely stored in a lockable cupboard, apart from creams that are appropriately stored in the fridge. The Inspector checked the Medication Administration Record (MAR) sheets for five people living in the home. The sheets are well completed by staff and the Inspector saw no errors or omissions. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to give their views. Staff from the home and the Learning Disability Team need to improve the way they work together to make sure people are safe. EVIDENCE: The home has a clear complaints procedure and one service user told the Inspector that they would speak to staff or the Manager if they had concerns. There have been no formal complaints recorded in the home since the last inspection in October 2005. Staff in the home record informal complaints and a good record is kept. This record shows the action taken to investigate and resolve issues raised by service users and others. Outcomes for people raising concerns are also well recorded. Since the last inspection, one adult protection investigation has been held that involves a person living in the home. The Inspector feels that this incident should have been managed more efficiently by staff in the home and the Learning Disability Team. CSCI should have been informed of the incident and invited to the strategy meeting that was held. The standard of recording minutes of the strategy meeting was very poor and no follow up meeting has been held. The home’s Manager must make sure that the local adult protection procedures are followed and CSCI are informed of any incidents. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from good standards of furnishing and decoration in their bedrooms and communal areas. EVIDENCE: The Inspector saw all communal parts of the home and three service users’ bedrooms. The last inspection report included requirements to refurbish the home, redecorate communal areas and provide new furniture and carpets. All these requirements have been met and the home now offers a good standard of accommodation. One person living in the home told the Inspector they thought everywhere ‘looks lovely’. All parts of the home were clean and tidy and the provision of new carpets and furniture has significantly improved the environment for people living in the home. Bedrooms are well furnished and decorated and staff have supported service users to make sure their rooms reflect their interests and personalities. There is a need to replace the radiator cover in the ground floor bathroom as this is badly corroded. Redecoration is also needed around the toilet in the first floor bathroom. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 15 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 and 35. 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 staffed to support service users and reliance on agency staff has been reduced. EVIDENCE: Staffing levels in the home have improved since the last inspection and there is now a minimum of two staff on duty at all times. When the Inspector arrived for this unannounced visit, two staff were on duty. The home’s Manager arrived at 09:30 and a third residential worker started work at 11:00. The staff team worked well together to make sure that all six service users were supported to take part in planned activities. The Inspector checked the home’s rota and this accurately showed the staff on duty. Previous inspection reports have highlighted the home’s reliance on agency staff and the possible negative effects on continuity of care. The Manager confirmed that a permanent Deputy Manager has been appointed together with two care staff on 6-month contracts. Two posts in the home are still covered by agency staff. The Manager, Deputy Manager and one residential worker have completed NVQ training and three other staff are also completing their NVQ qualifications. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 16 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, 40, 41, 42 and 43. 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, but more work is needed to make sure that service users’ views underpin the development of the service. EVIDENCE: The home now has a permanent Manager who is registered with the Commission. The Manager is supported by a permanent Deputy Manager and a team of residential workers. There is a need to make sure that the development of the service is based on the views of people living in the home and their relatives / representatives. The manager and the local authority have completed some good work to produce accessible information about plans to transfer the home to another provider, but this should be extended to other aspects of the service, eg staff recruitment. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 17 Information provided by the Manager before this inspection shows that the local authority has developed the policies and procedures needed to meet these Standards and these are regularly reviewed. Standards of record keeping in the home are good and all records checked during this visit were well maintained by staff. It is a recommendation of this report that care plan files are reorganised to reduce the amount of information that is kept. A working file with a copy of the current Person Centred Plan, risk assessments, minutes of the last review meeting and monthly summaries of care would be easier for staff to maintain. No health and safety issues were noted during this visit. Regular monthly monitoring visits are carried out by officers from the local authority and copies of reports are sent to the home and the Commission after each visit. 2 Coverdale Road DS0000035470.V289250.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 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 4 26 X 27 2 28 3 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 2 3 2 3 3 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 19 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 YA5 Regulation 5 [c] Requirement The local authority must introduce a costed contract / statement of terms and conditions for people living in the home. The home’s Manager must make sure that the local adult protection procedures are followed and CSCI are informed of any incidents. The radiator cover in the ground floor bathroom is badly corroded and must be replaced. Redecoration is also needed around the toilet in the first floor bathroom. Timescale for action 31/07/06 2. YA23 13 [6] 31/07/06 3. YA27 23 [2b] 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA39 Good Practice Recommendations The development of the service should be based on the views of people living in the home and their relatives / representatives. DS0000035470.V289250.R01.S.doc Version 5.1 Page 20 2 Coverdale Road 2. YA41 Care plan files should be reorganised to reduce the amount of information that is kept. 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 21 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 2 Coverdale Road DS0000035470.V289250.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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