Inspection on 30/06/05 for Fontenoy Road

This inspection was carried out on 30th June 2005.

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 5 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 12/12/05

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 30 June 2005 10:30 am th 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 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 Stationary 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 G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Fontenoy Road Address 10 Fontenoy Road London SW12 9LU Telephone number Fax number Email 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 Threshold Housing and Support Ms Alison Cameron James CRH Care Home 12 Category(ies) of LD Learning Disability (11) registration, with number PD Physical Disability (1) of places Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26/11/04 Brief Description of the Service: 10 Fontenoy Road is a residential home registered to provide care for up to twelve adults with a learning disability. The service is part of the Threshold organisation. It is situated in a quiet residential road close to local shops and amenities. The property is not identifiable as a care home from the outside. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector on the 30th June and 13th July 2005. The inspector spent approximately five hours in total at the home. The inspection included the examination of records, a partial tour of the premises and individual conversation with four residents, two relatives, the registered manager and three members of staff. What the service does well: What has improved since the last inspection? The renovations to the bathrooms on the first floor are now complete. These are of a high quality and the provision includes a large walk-in shower room. New cupboards have been installed in the main communal lounge / dining room which ensure that files in use can be locked away. Requirements regarding hot water temperatures from the previous inspection have been fully actioned and these are subject to ongoing weekly checks. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 6 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 G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 5. Written information is made available to prospective residents regarding the service. This documentation requires further minor amendment to ensure the accuracy of information presented. A satisfactor written procedure is in place to ensure that the needs of prospective residents are fully assessed prior to moving in to the home. A Statement of the applicable terms and conditions for the home is made available to residents. EVIDENCE: The organisational ‘referrals and admissions’ procedure ensures that prospective residents needs are assessed. Assessment documentation was found to have been updated for two residents whose care files were examined. Eleven residents were accommodated in the home at the time of this inspection visit. Copies of tenancy agreements are supplied to residents and these were seen to be kept within the examined care documentation. The registered manager reported that they were still developing a guide for residents in a video format. The intention was to provide information Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 9 regarding the home as well as reinforcing the rights and responsibilities of residents living there. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 6, 7, 8 and 9. The support (care) plans in place for residents are maintained to a high standard and ensure that individual needs of residents are addressed on an ongoing basis. Risk assessment documentation is in place as part of the process to allow residents to be as independent as possible. EVIDENCE: The care documentation examined for two residents was seen to be up to date and subject to an ongoing process of evaluation and review. Up to date support plans were seen to be in place covering areas of need such as levels of confusion, personal care and health. Support plans were observed to be in place with regard to the individual’s ability to access their documentation and to enable their full participation in the ongoing planning process. The registered manager reported that these were due to be produced in accessible formats such as pictures / audio. Risk assessments were seen to be in place for both residents whose documentation was examined. These were observed to address potential areas of risk for individuals such as the potential hazard from hot water. The Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 11 assessments examined were seen to be subject to regular documented audit and review. Three residents spoken to individually reported that they were satisfied with the overall service provided. Comments included ‘I’m happy living here’ and ‘I like living here with all of my friends’. The relatives of two residents both reported that they were kept well informed by the home and felt able to discuss any issues with the managers or staff. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 to 16. Residents are supported to take part in appropriate activities and to be part of the local community. The service promotes independence and individual choice for the residents accommodated. Individual dietary needs are well catered for. EVIDENCE: Residents participate in a variety of day activities. One resident reported that they attended a Day Centre and another stated that they had just commenced an office job for one day every fortnight. The registered manager reported that one resident no longer attended a day placement and received a tailored package of daily 1-1 support. This was proving to be very positive for the individual and improvements had been noticed in their communication skills. Residents are supported to engage in activities both in and outside of the home environment. The lounge area was seen to be equipped with television, digital free view, video, DVD and music equipment. A member of staff reported that one resident was a Chelsea season ticket holder and that they were supported to attend home games on a regular basis by staff. This was Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 13 confirmed by the resident who was seen to be watching a football video on the second day of inspection. One resident spoken to reported that they had recently been on holiday to Butlins and had ‘really enjoyed this. They stated that they regularly went out with staff for a ‘bite to eat’. A visitor commented that there were regular pub trips out for their relative and that they had received ‘good reports’ regarding the recent holiday provided to residents. Both relatives spoken to confirmed that they felt able to visit the home at any time and felt welcomed by the staff. One relative of a resident reported that staff at the home had helped them out personally and this was indicative of the caring nature of staff employed there. Feedback regarding the food provided was positive at the time of inspection. Comments included ‘I like the food’, ‘it’s alright’ and ‘I have my favourite foods’. The current menu was seen to be displayed in the kitchen and included meals such as chicken korma, vegetable pasta and sausage casserole. One resident has the responsibility of writing the menus and keeping the records up to date. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 14 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 standard(s) 18 - 20. Residents receive appropriate levels of support to ensure their physical health needs are met. Systems in place to ensure the safe administration of medication to residents require minor improvement. EVIDENCE: Personal care needs were seen to be well documented within individual care plan documentation examined for two residents. Care documentation examined showed that appropriate support was provided to ensure that individual physical health needs were met. Records of contact fully evidenced that individuals access GP, district nurse and optician services within the local community. Medication administration records were observed to be well maintained but further minor improvement is required to fully ensure the safe administration of medicines to residents. This is with regard to ensuring that medications that are no longer in use or are past their expiry dates are disposed of promptly. All items of medication were however observed to be securely stored and an organisational procedure was in place at the time of inspection. The registered Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 15 manager reported that care staff still required medication training from a creditable source. This has been made a Requirement within this report. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 16 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 standard(s) 22 An accessible complaints procedure is in place at the home. This ensures that resident’s views are listened to and acted upon. EVIDENCE: The complaints procedure in place was seen to have been produced in an accessible format utilising pictures and photographs. The registered manager stated that the home was planning to produce a video guide to the home and this would include information on the individuals right to complain. Available records evidenced that no complaints had been made to the home since the last inspection. Three residents individually spoken to expressed confidence in the staff to sort out any problems they may have. The relatives of two residents both reported that they were able to discuss any issues with the key worker or management of the home. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24, 25, 27, 28 and 30. 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. Sufficient accessible lavatories and washing facilities are available at the home and these afford privacy to the individual. The home is clean and hygienic. EVIDENCE: The premises were observed to be kept in generally good decorative order at the time of inspection. A large lounge / dining room is the main communal area in use by residents although another separate lounge is also provided. Two bathrooms and an impressive shower facility are provided on the first floor of the home and these have all recently been fully renovated. Requirements have been made regarding damage to the wall in the ground floor lounge and to ensure that the carpet in the dining room area is cleaned or replaced. The garden area of the home would certainly benefit from further work to ensure that this area is both accessible and safe for all residents to access. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 18 The files kept in the lounge area of the home have been stored in new cupboards installed since the last inspection took place. This ensures that the ‘office’ area for staff is not intrusive on the residents lounge / dining area. All residents spoken to were satisfied with their bedroom accommodation. The two bedrooms seen at the time of inspection were well maintained and personalised to the individual resident. The relative of one resident spoke of hoping to have the resident’s bedroom redecorated in the short-term – it is recommended that this issue is fully resolved at the next review meeting. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35. The residents receive good support from a competent, qualified and effective staff team. EVIDENCE: Suitable numbers of care staff are provided at the home. A minimum of two staff are on duty at the home at any one time. A waking night staff member and a sleep-in are on duty at night times. Comments received from residents regarding the staff included ‘I like the staff’, ‘they are all nice to me’ and ‘they treat me well’. Two relatives of residents stated that the staff were ‘fabulous’ and ‘very caring’. Staff appraisals were taking place at the time of inspection and these included assessment of individual training needs. An organisational training programme is in place to ensure that residents are supported by appropriately trained staff. This programme includes courses such as medication, Health and Safety, customer services and supervisory skills. One member of staff reported that they had recently undertaken a management training course provided by the organisation. The competency of staff members is further ensured through access to NVQ training. The registered manager stated that two members of staff have the Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 20 NVQ Level Three qualification with a further individual currently studying to attain this award. One member of staff has attained the NVQ Level Two qualification. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 and 42. Residents currently benefit from a well run home. The quality assurance system in place requires development to ensure that the views of residents and other stakeholders are formally obtained. Systems in place to ensure the health and safety of residents were found to require further minor review. EVIDENCE: The registered manager and her deputy have been in post for a number of years and continue to demonstrate their commitment in providing a high quality service to the residents accommodated. This is additionally apparent in the staff team as a whole who are to be commended for their ongoing work. Feedback from two visiting relatives was very positive and comments included ‘a very good home’ and ‘more than satisfied’. Two staff members were spoken Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 22 to individually and each stated that they felt one of the main strengths of the service was the way the staff team worked together. An organisational quality assurance system is in place. As reported within the previous inspection report, it is essential that the views of the residents, their representatives and other stakeholders be formally obtained as an integral part of this process. The registered manager reported that they were still planning to establish formal regular ‘family carers’ meetings at the home. The registered manager reported that residents meetings were held at least monthly but this was an area for potential development by the home. This would include a review of the format in use and to try to enable more ownership of these meetings by the residents themselves. Residents are protected by the Health and Safety systems in place at the home. Satisfactory records were observed to be maintained with regard to gas safety, electrical checks, hot water temperatures and fire equipment testing. Requirements have been made with regard to ensuring that First Aid boxes are checked monthly and that a full risk assessment is put in place with regard to Legionella. Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fontenoy Road Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 24 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 Timescale for action 01.08.05 2. YA20 13 (2) 18 (1) (c) 3. YA24 23 (2) (b) (c) (o) The Registered Persons must ensure that any disused or out of date medication is disposed of promptly by the home. The Registered Persons must 01.10.05 ensure that all care staff responsible for administering medication to residents receive training from a creditable source. The Registered Persons must 01.11.05 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. The Registered Persons must ensure that the views of residents, their representatives and other stakeholders are formally obtained as part of the quality assurance system in place. The Registered Persons must ensure that: Monthly checks of First Aid boxes 4. YA39 24 01.10.05 5. YA42 13 (4) Fontenoy Road G54-G04 S10190 Fontenoy Road V238711 300605 Stage 4.doc Version 1.40 Page 25 are carried out and recorded. A Risk assessment regarding Legionella is put in place for the home. 01.08.05 01.10.05 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 YA39 Good Practice Recommendations It is recommended that residents meetings held be developed to ensure they maximise participation / engagement by individuals. 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