Inspection on 15/11/06 for Fontenoy Road

This inspection was carried out on 15th November 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 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 7 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 12/12/05

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 Adrian Gordon Unannounced Inspection 15th November 2006 10:00 Fontenoy Road DS0000010190.V319626.R02.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 Fontenoy Road DS0000010190.V319626.R02.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. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 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.V319626.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 Brief Description of the Service: 10 Fontenoy Road is a care home for twelve adults with a learning disability. Staff support is provided 24 hours a day. The home is managed by Threshold Housing and Support. The home is located in a quiet residential road in Balham close to local shops and transport links and is in keeping with the neighbourhood. To the rear is a large garden area. Information about the service is provided in the Statement of Purpose. A video DVD of the home is currently being produced. Fontenoy Road takes referrals from the London Borough of Wandsworth Social Services Team. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector who spent six hours at the home. The inspector met the majority of residents and one relative. A number of records were examined and discussions took place with the manager, three members of staff and a live in volunteer. No feedback questionnaires were returned. What the service does well: What has improved since the last inspection? What they could do better: Although medication training has been provided to staff, there are still errors occurring in the way in which medication is administered and recorded. In order to protect residents a rigorous system must be put in place. Some improvements have been made to the environment but more must be done to ensure the home is kept clean and in a good state of repair for the benefit of residents. The registered persons must ensure that evidence is in place to show that all the necessary recruitment information has been obtained for staff working at the home. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 6 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. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 7 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.V319626.R02.S.doc Version 5.2 Page 8 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission so that the home is certain their needs can be met. EVIDENCE: There have been no new admissions to the home since the last inspection in December 2005. All residents are fully assessed before being coming to live at Fontenoy Road. Assessments held in resident files were of a good standard and contained a broad range of information, including residents’ strengths and needs. The manager commented that they are in the process of completing a video film about the home, which is aimed at new residents. The focus of the video is about rights, responsibilities and life at Fontenoy Road and has been made by residents and staff. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 9 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Well thought out support plans which are constantly reviewed ensure that the needs of residents are met. Good risk assessments promote the safety and independence of residents. EVIDENCE: Support plans are well written and regularly reviewed to ensure they are up to date. They include individual goals specific to each resident, for example one residents aim was to gain some form of employment. Personal identity and culture is included in care planning information. The manager said that one resident has an audio version of their support plan to help their understanding. Monthly keywork sessions ensure that staff are reviewing goals with each resident and also giving them an opportunity to make decisions about their life in the home. Records of these meeting are signed by the resident. Resident Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 10 meetings take place every two weeks. Formal care reviews were all up to date and showed good participation from residents. Risk assessments are in place for each resident and these are reviewed and updated regularly. These include areas of risk such as using knives, fire safety and restrictions on freedom. For example, one resident had a risk assessment regarding managing their own keys. No issues relating to equality and diversity were raised. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 11 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, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead good lifestyles of their choosing. EVIDENCE: Most residents attend a day centre where they can take part in activities such as music and art. Residents have their own routines and activities which they choose to do. For example, one resident enjoyed colouring in a book and was happy to show me some of the pictures they had completed. This resident also had some of their artwork on their bedroom wall. Other activities which residents take part in include going for walks, trips to the pub, shopping and cinema. Two residents have become engaged and are planning a wedding. They are being supported in this by staff. Another resident has a relationship with Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 12 someone who lives at a different home who is able to visit regularly. One relative who visited during the inspection said it was a ‘good home’. Meals are planned using a four week menu which shows a range of food offered to residents. One resident said that the food is ‘good’. Meals provided include fish and chips and chicken and rice. To celebrate one residents birthday recently they had a Caribbean meal. One resident has responsibility for confirming what option residents want before each meal and making a written record. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 13 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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health is promoted by staff. Medication systems must be improved to ensure that there is no risk of maladministration. EVIDENCE: The health needs of residents are made clear in written Health Plans. These also include details of appointments such as eye tests, dental checks and chiropody. Staff demonstrated a good understanding of individual health needs, for example a keyworker talked about a resident who was partially sighted, explaining what systems were in place to support them. Monthly keywork meetings offer residents the opportunity to discuss the support they receive and state any preferences they have. Each resident has a medication administration record (MAR) sheet. These showed some gaps in recording for the month of October 2006. The gaps were not spotted until the end of the month. A system must be implemented to ensure recording errors are spotted at handover to ensure residents have Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 14 received the correct medication. New policies and procedures for the administration of medication were introduced in July 2006. These are written in line with CSCI guidance. Although the new policy for ‘as required’ medication is clear, it was not being followed in practice. Some medication was found to be stored in the staff office but was not locked away. This is unsafe practice and suitable storage must be found. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 15 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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the procedures for complaints and the protection of vulnerable adults. EVIDENCE: A satisfactory complaints procedure is in place. No complaints have been received by the home or by the CSCI since the previous inspection in December 2005. Procedures are in place for the protection of vulnerable adults (POVA). These make reference to the CSCI and local inter agency procedures, however there is a need for some staff to attend POVA refresher training. Resident finances are suitably recorded and receipts of purchases kept. Finances are subject to a yearly audit and are checked during monthly provider visits. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 16 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, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment around the home is generally satisfactory but there is still a need for maintenance in some parts so that residents can fully enjoy their surroundings. EVIDENCE: The front lounge has been repainted and is now comfortable, light and homely. The dining room/lounge to the rear has a carpet which is quite old and which must be replaced. The walls would benefit from being repainted. This room was observed to be the place where most residents and staff gathered. The rear garden is a nice space for residents to enjoy but must be improved with some general maintenance as required at the last inspection. A large kitchen is accessible to all residents. One of the strip light covers held a large number of dead flies and this must be cleaned. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 17 Toilets, showers and baths are sufficient in number for the size of the home. The downstairs shower had a loose soap dispenser which needed refitting and the extractor fan was very dirty and must be cleaned. An upstairs bathroom had curtains which were hanging loose. This must be put right. Two bedrooms were seen on the ground floor. These were both comfortably furnished and personalised with pictures and photos. One resident said ‘I like it’. However one of the rooms had paint peeling from the ceiling and needed repainting. The other room had dark cobwebs on the ceiling and the window nets were dirty. More attention must be given to ensuring that resident rooms are kept clean. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 18 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, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent staff team meets the individual needs of residents. EVIDENCE: There are a minimum of two staff on duty at any one time and a full time livein volunteer is available as additional support. A waking night staff and sleep in person cover at night times. Residents and staff were observed to have positive relationships and there was good communication. The atmosphere was friendly and relaxed. Staff were well informed about the needs of residents. One resident said that staff are ‘fine’. Three staff files were examined. These all held evidence of a Criminal Records Bureau Check and references. However, two files did not have a photo of the staff member and one file did not have any proof of identification. There is no written confirmation from agencies that staff supplied have had all the necessary recruitment checks. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 19 Induction is given to new staff in line with the Learning Disability Assessment Framework. There is an induction checklist for new agency staff which was seen to be signed and dated by people using it. An induction file provides useful information about the home, however some of this was out of date and should be updated. There are good opportunities for training including core areas such as First Aid and Manual Handling. Medication training took place recently. The manager said that because of the changing needs of residents she has looked into training in dementia care awareness for all staff. Supervisions take place regularly and are recorded appropriately. Staff appraisals took place in May 2006, however, appraisal forms were incomplete and did not set goals for the coming year. Staff meetings occur every two weeks and are well recorded with good involvement from staff. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 20 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, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good management ensures that residents rights are promoted and their welfare is central to the service provided. EVIDENCE: The registered manager has been in post for a number of years. She holds the Registered Managers Award and is currently completing the NVQ4 in Care. The manager was observed to have a positive relationship with residents and staff. She has a very good understanding of residents strengths and needs and of the day to day routines in the home. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 21 Resident meetings take place every two weeks. Minutes showed that there is good involvement from residents and that their views are asked about different aspects of home life. For example there have been recent discussions about meals and all residents were asked about a new tenant that may be coming to stay. Monthly monitoring visits are taking place and reports are kept at the home. Systems are in place to ensure that the necessary health and safety checks are carried out. These include daily records of fridge/freezer temperatures and weekly fire point tests. Records showed that fire drills take place twice a year. Consideration should be given to making these more frequent. An environmental risk assessment and fire safety risk assessment are in place. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 22 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 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 2 X 3 X 3 X X 3 X Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 all gaps in medication assessment records (MAR) are accounted for, that MAR sheets contain information on the circumstances in which ‘as required’ medication is given, and that medication kept in the staff office is appropriately stored. The registered persons must ensure that all staff receive refresher training in the protection of vulnerable adults. The registered Persons must ensure that: the wall in the lounge is redecorated, the carpet in the lounge/dining room is cleaned or replaced, the garden is improved to make it more accessible and safe for residents to use. (Requirements carried Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 24 Timescale for action 01/01/07 2. YA23 13(6) 01/03/07 3. YA24 23(2)(b) (c) (o) 01/03/07 forward - previous timescales of 01/11/05 and 01/04/06 not fully met). 4. YA24 23(2)(d) The registered persons must ensure that the strip light cover in the kitchen is cleared of dead flies. 01/01/07 5. YA27 23(2)(b) (c) The registered persons must 01/02/07 ensure that the soap dispenser is refitted and the extractor fan cleaned in the downstairs shower room. The registered person must ensure that net curtains are kept clean and cobwebs on ceilings are removed. The registered persons must ensure that recruitment information held on staff is in line with Schedule 2 of the Regulations, and obtain confirmation from agencies that this has been carried out for their staff. 01/01/07 6. YA30 23(2)(d) 7. YA34 19, Schedule 2 01/02/07 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 YA32 YA36 Good Practice Recommendations The registered persons should ensure that information in the induction file is updated. The registered persons should ensure that staff appraisals are completed for each member of staff annually. Fontenoy Road DS0000010190.V319626.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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