Inspection on 18/12/06 for Elmfield Way, 1-2

This inspection was carried out on 18th December 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 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 01/02/06

Elmfield Way, 1-2 03/03/05

Elmfield Way, 1-2 13/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

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 18th December 2006 10:00 Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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 info@yarrowhousing.org.uk Yarrow Housing Limited Caryl Anderson Care Home 6 Category(ies) of Learning disability (18) registration, with number of places Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 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.V320825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Monday 18th December 2006 from 10:00 am – 3:00 pm. The Inspector spoke with service users, the home’s Manager and staff and checked care records kept in the home. The home provides good standards of care and accommodation. Managers and staff have a good understanding of equalities issues and there are sufficient staff to support service users to take part in community activities. The weekly fee for the service varies from £2,485 - £2,671. One service user and three relatives / visitors returned confidential questionnaires sent out as part of this visit. Their comments are included 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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.V320825.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been no change to the service user group since the last inspection. There are clear referral and admission procedures in place. EVIDENCE: The group of people living at Elmfield Way have lived together for the past 3 years. Evidence provided by the manager before this inspection is evidence that the home has clear policies and procedures for the referral and admission of new people, when vacancies occur. The home’s Manager confirmed that plans have started to support one person to move to another home managed by Yarrow, early in 2007. The Inspector was concerned that a transition plan has not yet been agreed, although the person’s parents have visited the new home and support the move. Staff from Elmfield Way must make sure that a transition plan is developed that includes visits to and overnight stays at the new home. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. 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 care plan that is regularly reviewed and is supported to be as independent as possible. EVIDENCE: During this visit the Inspector tracked the care received by two people living in the home. The Inspector spoke with both people and staff responsible for their care. Each person’s care plan file included a current service user plan. Each plan included some clear goals based on the person’s care needs and details of how they would be met in the home. The inspector felt that standards of risk management in the home are very good. The two care plan files included risk assessments covering a wide range of potential risks, including access to the local community, use of public transport, use of the kitchen, road safety, bike riding and cooking. One file also included a night care risk assessment. Each of the risk assessments included clear guidance for staff on minimising the identified risk and all had been recently reviewed. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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. The home is well staffed and service users are able to take part in a range of activities of their choice. EVIDENCE: During this visit, all six service users spent time taking part in activities outside the home, supported by staff. One person had spent the weekend with his parents and was due to return home in the afternoon. Two people went to planned day services. Staff supported the other three service users to go out to local shops and for longer walks. The Inspector checked the daily log books for two people living in the home. The logs showed that the two people are supported regularly to go out for meals, trips to the cinema and ten-pin bowling. Both people also had a holiday during 2006. Care plans include details of service users’ relatives, friends and other significant people. One service users’ parents also visited them at the home during this inspection. Three service users’ relatives returned confidential Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 10 questionnaires sent out as part of this inspection. All were very positive about the care and support provided at Elmfield Way. One person commented ‘we are always greeted with a cheery welcome and (our relative’s) needs are being met by the staff’. Staff supported one service user to complete a questionnaire and they commented that they can make decisions about what they do each day and can do what they want during the day, in the evenings and at weekends. The home has a large lounge / dining room and a new dining table and chairs have been provided since the last inspection. During this visit the Inspector saw staff encouraging service users to make choices about what they wanted to eat for breakfast. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. 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. The personal care needs of people living in the home are well recorded and individuals are supported in the ways they choose. EVIDENCE: During this visit, the gender mix of staff on duty enabled same gender support with personal care to be provided, if required. The inspector felt that the staff team worked well together to make sure that each service user was supported in the ways they chose, by staff known to them. Both of the care plan files checked by the Inspector included up to date Health Action Plans that detailed each person’s health care needs and how these would be met by staff in the home and clinicians. Both Health Action Plans were evidence of appropriate referrals to local health care professionals. The Inspector also checked the home’s medication management systems. The home uses a monitored dosage system provided by Boots. All prescribed medication is delivered every 28 days in blister packs. The Inspector checked the Medication Administration Record (MAR) sheets for all six people living in the home. All six records were well completed and there were no errors. Medication is securely stored in an appropriate cabinet in the home’s main office. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. 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. Service users are supported to use an accessible complaints procedure and their personal finances are well managed by staff. EVIDENCE: Information provided by the Manager before this inspection is evidence that there have been no formal complaints since the last inspection. Three relatives who returned confidential questionnaires said that they were aware of the home’s complaints procedure. The complaints procedure has been produced using Plain English, line drawings and photographs to make the information more accessible to people living in the home. The Inspector checked the finance records for two people living in the home. Both records were well maintained by staff and receipts are obtained for each transaction. The home’s Manager must check why one person paid for the central London congestion charge on a day when the log book showed she did not go out. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 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. The home provides a good standard of private and communal accommodation that meets the needs of individual service users. EVIDENCE: 1 and 2 Elmfield Way 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 Inspector saw all communal areas and 5 service users’ bedrooms. Most parts of the home are well decorated and comfortably furnished and bedrooms in particular reflect the personality and interests of service users. The main kitchen is in need of redecoration and this should be included in the maintenance programme for 2007-2008. Three issues need to be addressed by the home’s Manager. The home’s fire safety risk assessment must be reviewed; the shower in the pink side bathroom has been broken for nine months and must be repaired without further delay and thermometers must be provided in fridges and freezers. All parts of the home were clean and hygienic during this visit. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are well supported by a team of experienced and qualified managers and care staff. EVIDENCE: During this visit the home’s Manager was on duty, supported by a team of six care staff. The Inspector felt that the staff team worked well together throughout the day to make sure that service users were supported with activities of they chose. Information provided by the Manager before this inspection is evidence that 98 of the permanent care staff employed at Elmfield Way have completed their NVQ Level 2 or 3 qualification training. As well as NVQ training staff have also completed training in Food Hygiene; Autism; Manual handling; Physical Intervention; Fire Safety and Person Centred Planning. The home has a large team of 21 care staff and although there are currently 6 vacancies, these are covered by bank staff from within the organisation. This system makes sure that people living in the home usually are supported by people they know. All staff working in the home have an Enhanced Disclosure from the Criminal Records Bureau and a record of all checks is kept in the home for reference. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 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. 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 has a permanent Manager who provides clear leadership to the staff team. EVIDENCE: The home’s Manager was appointed in December 2006. Before this she had been one of the home’s Deputy Managers for the previous 18 months. The home has been without a registered manager for more than a year and the current Manager must apply to the Commission for registration without delay. Information provided by the Manager before this inspection is evidence that the home has all the policies and procedures needed to meet these Standards. Staff who spoke with the Inspector were aware of the home’s policies and procedures and all knew that copies were kept in the office for reference. The Inspector checked health and safety records kept in the home and these were well maintained. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 16 Monthly monitoring visits are carried out by managers from the provider organisation and copies of reports are kept in the home for reference. Managers responsible for completing monitoring visits must make sure that sufficient detail is included in their reports to effectively assess the day to day running of the home. Where finance officers carry out visits on behalf of the organisation, the Manager must make sure that their reports are kept in the home. Reports completed by finance officers must also include an assessment of other aspects of the care provided. Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 17 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 2 5 X 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 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 3 3 3 2 Elmfield Way, 1-2 DS0000010873.V320825.R01.S.doc Version 5.2 Page 18 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 YA4 Regulation 12 Requirement When service users move on from the home, staff must make sure that a transition plan is developed that includes visits to and overnight stays at the new home. The home’s Manager must check why one person paid for the central London congestion charge on a day when the log book showed she did not go out. The home’s fire safety risk assessment must be reviewed; the shower in the pink side bathroom has been broken for nine months and must be repaired without further delay and thermometers must be provided in fridges and freezers. The Manager must apply to the Commission for registration without delay. Where finance officers carry out visits on behalf of the organisation, the Manager must make sure that their reports are kept in the home. Reports completed by finance officers must also include an assessment of other aspects of the care provided. DS0000010873.V320825.R01.S.doc Timescale for action 31/01/07 2. YA23 13 31/01/07 3. YA24 23 31/01/07 4. 5. YA37 YA43 9 26 31/01/07 31/03/07 6. YA43 26 31/03/07 Elmfield Way, 1-2 Version 5.2 Page 19 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 YA24 Good Practice Recommendations Redecoration of the main kitchen should be included in the maintenance programme for 2007-2008. 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