Inspection on 01/02/06 for Elmfield Way, 1-2

This inspection was carried out on 1st February 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmfield Way, 1-2 29/01/08

Elmfield Way, 1-2 21/08/07

Elmfield Way, 1-2 18/12/06

Elmfield Way, 1-2 03/03/05

Elmfield Way, 1-2 13/10/04

Similar services:

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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 Elmfield Way, 1-2 1-2 Elmfield Way London W9 3TU Lead Inspector Tony Lawrence Unannounced Inspection 1st February 2006 10:00 Elmfield Way, 1-2 DS0000010873.V280547.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 Elmfield Way, 1-2 DS0000010873.V280547.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. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmfield Way, 1-2 Address 1-2 Elmfield Way London W9 3TU 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) 020 7266 1200 020 7266 3412 Yarrow Housing Limited Caryl Anderson Care Home 6 Category(ies) of Learning disability (18) registration, with number of places Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th September 2005 Brief Description of the Service: 1-2 Elmfield Way is a registered care home providing accommodation and personal care for six people with autism and/or challenging behaviours. At the time of this visit there were 4 men and 2 women living in the home and no vacancies. Kensington Housing Trust owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is located off Harrow Road, a busy main road. It is close to local shops and transport links. Originally built as two separate units, the home has been converted to provide spacious accommodation that is fully accessible to people using wheelchairs. The home is well staffed to provide intensive support to people with high care needs. Elmfield Way, 1-2 DS0000010873.V280547.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 Wednesday 1st February 2006 from 10:00 – 12:30. The Inspector spoke with staff and service users, checked care records and saw some parts of the building. Two people living in the home were out at day services. Staff were planning activities and outings for the other four service users. Three of the six requirements made at the last inspection have been met. One requirement should be met within the original timescale. Two requirements are repeated. 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. Elmfield Way, 1-2 DS0000010873.V280547.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 Elmfield Way, 1-2 DS0000010873.V280547.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): EVIDENCE: Key Standard 2 was met at the last inspection in September 2005. Elmfield Way, 1-2 DS0000010873.V280547.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 and 9. Standards of care planning and risk management are good. Service users’ care needs are well known to staff. EVIDENCE: Key Standard 7 was met at the last inspection in September 2005. The last inspection report included a requirement that care plans must include information on how agreed goals are measured and reviewed. During this visit the Inspector checked the Person Centred Plans (PCPs) for two people living in the home. The plans were reviewed in November and December 2005 and both included some clear goals and information about how these would be met. The Inspector also saw good monthly summaries of individual’s care and these are directly related to goals identified in the PCP. Risk assessments have also been completed for both service users. These identify all possible risks to individuals and detail how these will be minimised. While the standard of assessment is good, staff must make sure that all risk assessments are reviewed regularly. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 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 the following standard(s): 12 and 13. Service users are supported to take part in a range of appropriate activities. EVIDENCE: All Key Standards were met at the last inspection in September 2005. During this visit, two people living in the home were out at day services. The Inspector checked the activities programmes for two other service users and these show that a range of appropriate activities is offered during the week and at weekends. Staff worked well together during the morning to make sure that each person was offered an activity, either in the home or in the local community. Staff are very aware of one person’s behaviours and indicators that they may not want to take part in an activity. In response, staff made sure that the person was allowed to direct the care they received and make a positive choice to go out later in the day. Throughout this visit the Inspector was impressed with the positive interaction between staff and people living in the home. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 10 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): 20. The home has clear policies and procedures for the management of prescribed medication but staff must make sure that these are followed. EVIDENCE: Key Standards 18 and 19 were met at the last inspection in September 2005. All prescribed medication is supplied in blister packs that are delivered each month by Boots. Secure storage for medication is provided in the home’s office. During this visit the Inspector checked the Medication Administration Record (MAR) sheets for all six people living in the home. Although the records were up to date and generally well completed, staff must make sure that they sign the MAR sheet at the time they give a person their medication. Signing the medication record sheets must not happen later in the shift. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 11 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. Systems are in place to make sure that service users are consulted about the care they receive. People living in the home are cared for safely. EVIDENCE: Both of the care plans checked by the Inspector during this visit included evidence that service users and their representatives are consulted about the care and support provided in the home. Independent advocates are also available to support service users. Person Centred Plans clearly include references to individual’s preferences, wishes and aspirations. Weekly programmes of activities are linked to goals identified in the care plan. The last inspection report included a requirement that the use of service users’ personal money must be reviewed. During this visit the Inspector checked the finance records for two people living in the home. Both records were well completed and concerns raised at the last inspection have been addressed. Financial records are regularly checked by the home’s Manager and are also audited by the organisation. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 12 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, 28 and 30. The home provides a good standard of private and communal accommodation. EVIDENCE: Elmfield Way is a single storey building, purpose built to provide fully accessible accommodation. Divided into two, each side of the home contains 3 single rooms, bathrooms and toilets. Communal areas, including a large wellequipped kitchen and spacious lounge/dining room, connect the two sides. There is a large garden with an attractive ‘summer house’ that provides additional communal space for service users. The home has a sufficient number of toilets, bathrooms and showers and these are located close to service users’ bedrooms and communal areas. During this visit all parts of the home were clean and tidy. A requirement was made after the last inspection that the lounge, dining room and kitchen must be redecorated. The senior member of staff said that this work is due to be completed within the given timescale and new bathroom flooring will also be provided. It is a requirement of this report that new furniture must be provided in the lounge to replace broken chairs and sofas. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 13 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): 31, 32 and 33. The home is well staffed to meet the care needs of service users. EVIDENCE: Key Standards 32, 34 and 35 were met at the last inspection. During this inspection, seven members of staff were on duty. The home’s manager was attending meetings at the organisation’s Head Office. The Inspector feels that this level of staffing is sufficient to meet the needs of people living at Elmfield Way. The staff team worked well together to make sure that each service user received the care and support s/he needs. It is a recommendation of this report that a master copy of the staff rota should be produced, showing the staff who work each day and the hours they work. Although this information is available in a number of different documents, it is not easy to collate and the Inspector found it difficult to calculate the number of staff on duty during this visit. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 14 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, 41, 42 and 43. The home is well managed but there is a need to address one health and safety issue. Support to the home from senior managers must be improved. EVIDENCE: Key Standards 37 and 42 were met at the last inspection in September 2005. Following this inspection, the home’s Manager confirmed that he has applied to the Commission for registration and this is being processed. Person Centred Plans clearly show that the views of service users and their representatives are considered as part of annual reviews of the service and individual care plans. Independent advocacy is provided and service users’ families are also involved wherever possible. There is good evidence in care plans of good joint working with families and health and social care professionals. During this visit the inspector checked a variety of records, including medication and finance records, health and safety records, care plans and risk assessments. Standards of record keeping in the home are good. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 Page 15 While staff are recording food storage temperatures in one fridge and a freezer, the temperature in the second fridge is not recorded. Temperatures in the fridge that is checked also show that food is stored above the safe temperature of 5° C. Staff must make sure that both fridge temperatures are checked and recorded daily and safe temperatures must be maintained. Yarrow Managers are required to carry out unannounced visits to the home each month to monitor the day-to-day running. A written report must be sent to the home and the Commission following each visit. The Inspector checked the home’s records and there have been no recorded visits since September 2005. Senior Managers are not following up issues of concern and their support of the home, service users and staff is poor. Yarrow must make sure that a monthly visit is made to the home and copies of monitoring reports must be sent to the Commission for information. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 3 X 3 2 2 Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 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. 2. 3. 4. Standard YA9 YA20 YA28 YA28 Regulation 13 13 23 23 Requirement All risk assessments must be reviewed regularly. Staff must sign medication records when they give a person medication, not later in the shift. New furniture must be provided in the lounge to replace broken chairs and sofas. The lounge / dining room and kitchen must be redecorated. Repeat Requirement – original timescale of 30/04/06 stands. Staff must ensure that food is stored at safe temperatures. Staff must also make sure that both fridge temperatures are checked and recorded daily. Repeat Requirement – original timescale of 31/10/05 not met. Copies of monthly monitoring reports must be kept in the home and sent to the Commission. Repeat Requirement – original timescale of 31/10/05 not met. Timescale for action 31/03/06 31/03/06 31/03/06 30/04/06 5. YA42 16 31/03/06 6. YA43 26 31/03/06 Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 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. 2. Refer to Standard YA31 YA42 Good Practice Recommendations A rota should be available that clearly shows staff on duty and the hours they work. A lid is needed for the kitchen bin. Elmfield Way, 1-2 DS0000010873.V280547.R01.S.doc Version 5.1 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. 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