Inspection on 12/12/05 for Fontenoy Road

This inspection was carried out on 12th December 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

Fontenoy Road 23/10/07

Fontenoy Road 15/11/06

Fontenoy Road 30/06/05

Fontenoy Road 26/11/04

Fontenoy Road 05/08/04

Fontenoy Road 16/02/04

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 Fontenoy Road 10 Fontenoy Road London SW12 9LU Lead Inspector Jon Fry Unannounced Inspection 12th December 2005 13:45 Fontenoy Road DS0000010190.V275343.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 Fontenoy Road DS0000010190.V275343.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. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Fontenoy Road Address 10 Fontenoy Road London SW12 9LU 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 8675 1000 0000 jamesa@threshold.org.uk www.thresholdsupport.org.uk Threshold Housing & Support Ms Alison Cameron James Care Home 12 Category(ies) of Learning disability (11), Physical disability (1) registration, with number of places Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: 10 Fontenoy Road is a care home for twelve adults with a learning disability. The home is located in a quiet residential road in Balham close to local shops and transport links. The home is run by Threshold Housing and Support. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 12th December 2005. The inspection took place over three hours. The inspector spoke with six residents and two members of staff. A number of records were examined, as well as a tour of the communal areas of the home. 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. Fontenoy Road DS0000010190.V275343.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 Fontenoy Road DS0000010190.V275343.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 Residents benefit from their needs being appropriately assessed before admission. EVIDENCE: There have been no new admissions to the home since the last inspection took place in June 2005. There is an appropriate assessment procedure to make sure that the individual needs of a prospective resident are fully understood before they move into the home. A satisfactory assessment had been completed for one resident whose care file was examined. This document was being reviewed and updated at the time of this inspection. Fontenoy Road DS0000010190.V275343.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. The support (care) plans for residents are kept to a high standard and make sure that individual needs of residents are addressed on an on-going basis. Staff carry out individual risk assessments to promote the safety and independence of residents. EVIDENCE: The support plan for one resident was looked at during this inspection. This document was well organised and clearly showed a ‘live’ process of support planning for the individual resident. The plan covers areas of need such as cooking skills, work and health. Risk assessments had been produced for the resident whose documentation was examined. These address potential areas of risk such as access to knives and hot water. The documentation is kept under review by the home. Fontenoy Road DS0000010190.V275343.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): 17. Staff support residents in making menu choices and encourage individuals to have a healthy and varied diet. EVIDENCE: Residents spoken to were positive regarding the food provided – comments included “I like the food”, “good” and “it’s alright”. Two residents spoke about how they enjoyed a recent trip out with staff to have a Christmas dinner at a restaurant. A four-week revolving menu is in operation and this includes meals such as fish and chips, vegetarian pasta and chicken and rice. One resident at the home continues to write the menus and keep the records up to date. Fontenoy Road DS0000010190.V275343.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. Overall good medication systems are in place for the protection of residents. One minor shortfall was however observed at the time of this inspection. EVIDENCE: An organisational procedure for medication is available for reference by staff. Medication administration records are well maintained at the home. A good system is in place to make sure that medication is correctly given as prescribed. The main supply of medication is securely stored at the home. One instance was seen where a prescribed cream that was not in everyday use was past its use by date as marked on the packaging. Two members of support staff on duty reported that they had not yet attended any medication training. The Requirement made in the June 2005 report has been re-stated. Fontenoy Road DS0000010190.V275343.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. An appropriate complaints procedure is in place at the home. Satisfactory procedures are additionally in place for the protection of vulnerable adults. EVIDENCE: An accessible complaints procedure is in place. No complaints have been received by the home or by the CSCI since the previous inspection in June 2005. Clear procedures regarding abuse are available to make sure that staff have an understanding of their role and responsibility in reporting any concerns to the appropriate persons. One resident spoken to said that they would talk to their key worker or the manager if they had any problems or concerns. Another resident stated that they had “no problems”. Fontenoy Road DS0000010190.V275343.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 and 25. The standard of accommodation is generally good providing residents with a comfortable and homely place to live. Minor shortfalls were observed at the time of inspection. EVIDENCE: The home provides homely accommodation to residents that is generally maintained to a satisfactory standard. Available communal space includes a main lounge and dining area, a separate lounge area, large kitchen and a garden. The bedrooms of two residents were seen during this visit with their permission. Both were comfortably furnished and personalised to the individual. All residents spoken to said that they were satisfied with their bedroom. All areas of the home seen on this visit were generally clean and tidy. Requirements have been made within this report about the following maintenance issues: kitchen – the cooker hood requires cleaning, Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 13 ground floor hallway – the light shades require replacement, front lounge – damage to the wall requires re-decoration, dining area – the carpet presents poorly and requires further cleaning or replacement, garden – this area would benefit from further work to make it accessible and safe for all residents to use. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 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. An effective staff team meets the individual needs of residents. Good opportunities are provided for staff to take part in training. The home must however make sure that all individuals have received up to date training in areas such as First Aid, Food Hygiene and Medication. EVIDENCE: Suitable numbers of support staff are provided at the home. A minimum of two staff are on duty at the home at any one time with a full-time live-in volunteer also being available. A waking night staff member and a sleep-in are on duty at night times. Comments from residents included “the staff are nice”, “good” and “ok”’. One resident said that the staff sometimes “bossed them about” when doing household tasks such as bedroom cleaning and laundry but at other times they were “nice”. An organisational training programme is in place to ensure that residents are supported by appropriately trained staff. Two members of staff on duty said that they still needed medication training and one individual stated they required refresher training in First Aid and Food Hygiene. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 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): 37, 39 and 42. Residents benefit from a well run home. Systems in place to ensure the health and safety of residents were found to require further review. EVIDENCE: The registered manager has been in post for a number of years and continues to manage a strong team providing a high quality service to the residents living there. A new deputy manager has been appointed since the June 2005 inspection visit. Fortnightly resident meetings take place and include discussion about areas such as holidays and activities. The minutes of these meetings are discussed within the monthly staff meetings. Individual key work sessions are held with each resident and relatives or representatives of residents are invited to be involved with these sessions as appropriate. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 16 A new Health and Safety system has been introduced at the home since the last inspection took place. The home must make sure that full and accurate daily records are maintained for fridge and freezer temperatures and also for weekly fire point testing. The member of staff on duty reported that these shortfalls had been addressed at a recent staff meeting and prompts were now included in the home diary to ensure that checks were completed. Records to confirm that a Legionella risk assessment has been carried out were not available to the inspector. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 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 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 2 25 3 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X 3 X X 2 X Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The Registered Persons must ensure that any disused or out of date medication is disposed of promptly by the home. (Requirement carried forward previous timescale of 01/08/05 not fully met). 2. YA20 13 (2)18 (1) (c) The Registered Persons must 01/04/06 ensure that all care staff responsible for administering medication to residents receive training from a creditable source. (Requirement carried forward previous timescale of 01/10/05 not fully met). 3. YA24 23(2)(b) (c) (o) The Registered Persons must ensure that: damage to the wall in the lounge is repaired / re-decorated, the carpet in the lounge / dining room is cleaned or replaced, the garden is accessible and safe for residents to use. Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 19 Timescale for action 01/04/06 01/04/06 (Requirements carried forward previous timescale of 01/11/05 not fully met). 4. YA24 23(2)(b) (c) The Registered Persons must ensure that: the cooker hood is cleaned, the light shades in the ground floor hallway are replaced. 5. YA35 18 (1) (c) The Registered Persons must 01/04/06 ensure that all care staff receive up to date training in medication, First Aid and Food Hygiene. The Registered Persons must ensure that: full and accurate records are kept for daily checks of fridge and freezer temperatures, full and accurate records are kept for weekly checks of fire points, a full risk assessment of the premises regarding Legionella is carried out. 01/04/06 01/04/06 6. YA42 13 (4) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Fontenoy Road DS0000010190.V275343.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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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