Inspection on 06/10/05 for Coverdale Road (2)

This inspection was carried out on 6th October 2005.

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 6 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) 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 6th October 2005 09:30 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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.V256561.R01.S.doc Version 5.0 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.V256561.R01.S.doc Version 5.0 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.V256561.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th April 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. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 6th October 2005 from 09:30 – 12:30. The Inspector spent time talking with service users, care staff and the home’s manager. He also reviewed care records to check the care received by two people living in the home. While overall standards of care are good, the standard of accommodation is poor. Six of the twelve requirements made after the last inspection have not 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.V256561.R01.S.doc Version 5.0 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.V256561.R01.S.doc Version 5.0 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. The local authority has clear referral and admission policies and procedures, ensuring that service users make an informed choice to move into the home. EVIDENCE: The Inspector talked to service users and staff to assess this Standard. There have been no new admissions to the home since the last inspection and two service users told the Inspector that they have lived in the home for 20 years. Staff said that, if a vacancy were available, referrals would come from the multi-disciplinary Learning Disability Team. People referred to the home would be encouraged to visit before making a choice to move in. The number of visits would depend on the needs of the person referred and would include overnight stays if needed. The Inspector checked two care plan files and each contained a copy of the home’s Service User Guide. This includes the rights and responsibilities of people living in the home. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 and 9. The home’s standards of care planning are satisfactory and standards of risk management are good, ensuring service users are cared for safely. EVIDENCE: To assess these Standards the Inspector spoke to two service users and two care staff and checked care records. Both care plan files included an up to date care plan and a review meeting had been held for both service users in January 2005. Each plan includes clear, measurable goals and it was possible in some cases to see that these have been achieved. For example, a review meeting in January 2005 agreed that the service user needed an assessment by an Occupational Therapist as they were finding it increasingly difficult to get in and out of the bath. The home’s manager made the referral, an assessment was completed in June 2005 and handrails and grab rails were fitted on staircases and in the bathroom in July 2005. The service user told the Inspector that this had made using the bath and stairs much easier. While it was not possible to prove that some goals have been met, monthly summaries of care received by individuals were evidence that service users are fully involved in directing their care. Each care plan includes an ‘Essential Information’ sheet that describes 10-12 things that are especially important to 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 Page 9 the individual service user. These included contact with family, food likes and dislikes, routines and preferences. Some goals the Inspector felt should have been easy to achieve have not yet been met. For example, both service users said in their care plans that they would like to go to a football match. When asked by the Inspector, one person said that he used to go with his father when he was younger but he hadn’t been recently. Staff said that applications have been made for concessionary tickets, but the Inspector felt that the home or the service users themselves could have funded this relatively inexpensive activity. Standards of risk management in the home are good. Risk assessments are in place for both service users. These cover fire safety, mobility, nutrition, making coffee and use of the bathroom. The assessments are well written and up to date. In particular, the Inspector was impressed with one risk assessment that had been completed before a service user went on holiday. His considered the possible risks involved in travelling and staying away from home and detailed how staff supporting the service user would manage these. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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): 15. Staff in the home make sure that service users are supported to stay in touch with relatives, friends and other important people. EVIDENCE: The inspector saw two care plan files and each contains information about the person’s next of kin, other family members, friends and other important people. Two service users told the Inspector that they see relatives and friends regularly. Both people said that staff help them to phone other people and buy cards and presents or birthdays, Christmas and other special occasions. Care plans also include details of service users’ friends and how they will be supported to keep in touch. One care plan included information that the service user has a friendship with a person living in another care home. Monthly summaries of care written by staff from Coverdale Road show that this friendship is encouraged and the two people concerned are supported to visit each other. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 the following standard(s): 21. Service users’ personal and health care needs are well recorded and people are well cared for in the home. EVIDENCE: The key standards were met at the last inspection in April 2005. Both care plans the Inspector saw included clear information about the person’s personal and health care needs. Both files also included a record of any medical appointments. The manager must ensure that the Commission is informed of any significant events affecting the welfare of service users, for example any admission to hospital. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 the following standard(s): 23. While service users are cared for safely, there is a need to ensure that individual’s personal money is used appropriately. EVIDENCE: The main issue arising from the inspector’s assessment of this Standard is the need to review the provision of an annual holiday for each person living in the home, and the way in which this is paid for. The home’s Manager confirmed that the local authority has not contributed towards the cost of an annual holiday for service users in 2005-2006. This decision was not known until September 2005 and this made holiday planning difficult for service users and staff. As a result, service users had a reduced choice of holidays and it was not possible to make sure that each person went on the holiday they wanted. One person paid £845 for a week’s holiday in Scotland. The cost of the holiday included the service user paying for rail fares and accommodation for himself and the member of staff supporting him. The Council’s refusal to contribute towards the cost of a holiday means that people with a very limited income are paying substantial sums from their savings for a holiday each year. The use of service users’ personal money to pay for staff supporting them on holiday should be reviewed and the local authority should reconsider its decision not to include the cost of an annual holiday in service users’ individual contracts. The service user also paid for all the meals he had while on holiday. The National Minimum Standards say that a home must provide three meals a day plus drinks and snacks. Money paid by service users for food while on holiday must be refunded. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 27, 28, 29 and 30. The standard of décor is poor with little evidence of improvement since the last inspection. The home does not present as a homely and 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, toilets and the garden are shared. The major issue arising from the last inspection in April 2005 was the need to significantly improve the standards of decoration and furnishings in the home. Little progress has been made, agreed timescales of 01/11/05 have not been met and the home is shabby and unwelcoming. The manager confirmed that work would be completed by the end of 2005. The local authority must ensure that suitable arrangements are made to ensure disruption to people living in the home is minimised while these essential works are carried out. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 35. Some new staff have been appointed since the last inspection, providing more continuity for service users. There is still a need to review staffing levels and ensure all staff complete qualification training. EVIDENCE: The manager confirmed that, following recent interviews, there are now three permanent staff in the home and two staff on temporary contracts. One vacancy is covered by an agency worker who has worked in the home for some time. An additional 36 hours is provided to meet the increased care needs of some people living in the home. The manager confirmed that she has completed her NVQ Level 4 training and the deputy manager is completing their NVQ Level 3. One support worker will start the NVQ Level3 training in November 2005 and three staff are completing their Learning Disability Award Framework (LDAF) induction training. During this inspection three staff were on duty and the home’s manager started her shift later in the day. While the Inspector felt that this is an appropriate level of staffing to meet service users’ needs, the manager and staff said that only one member of staff is on duty for approximately 30 of the working week. The last inspection report included a requirement that two staff must be on duty at all times. This has not been met and the requirement is repeated in this report. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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 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): 41 and 42. Staff keep accurate records of the care and support given to people living in the home. Standards of health and safety are satisfactory. EVIDENCE: The key standards were met at the last inspection in April 2005. During this visit, the Inspector checked care plans, finance and medication records for people living in the home. All records are up to date and well maintained. In particular, monthly summaries of care provide clear evidence service users are well supported to take part in a wide range of activities. The Inspector saw no health and safety issues during this visit. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 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. 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 X 3 X X 3 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 2 Coverdale Road Score X X X 2 Standard No 37 38 39 40 41 42 43 Score X X X X X 3 3 DS0000035470.V256561.R01.S.doc Version 5.0 Page 17 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 YA21 Regulation 37 Requirement The manager must inform the Commission of any significant event affecting the welfare of service users. The local authority must review the use of service users personal money to pay for food. In particular, money paid by service users for food while on holiday must be refunded. (Timescale of 01/09/05 not met). Flooring in the lower ground floor lounge must be replaced. (Timescale of 01/11/05 will not be met). The local authority must ensure that suitable arrangements are made to ensure disruption to people living in the home is minimised while essential works are carried out. Agreed timescales for the replacement of furniture and carpets must be met. (Timescale of 01/11/05 will not be met). A minimum of two staff must be on duty at all times. (Timescale of 30/06/05 not met). Timescale for action 31/12/05 2. YA23 20 31/12/05 3. YA24 23 31/12/05 4. YA24 23 31/12/05 5. YA26 23 31/12/05 6. YA33 18 31/12/05 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 Page 18 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 YA23 Good Practice Recommendations The use of service users’ personal money to pay for staff supporting them on holiday should be reviewed. The local authority should also reconsider its decision not to include the cost of an annual holiday in service users’ individual contracts. 2 Coverdale Road DS0000035470.V256561.R01.S.doc Version 5.0 Page 19 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.V256561.R01.S.doc Version 5.0 Page 20 - 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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