Inspection on 06/12/05 for Great Western Road, Flat 3, 22-24

This inspection was carried out on 6th 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Great Western Road, Flat 3, 22-24 22/06/09

Great Western Road, Flat 3, 22-24 11/08/08

Great Western Road, Flat 3, 22-24 25/06/07

Great Western Road, Flat 3, 22-24 02/05/06

Great Western Road, Flat 3, 22-24 27/06/05

Great Western Road, Flat 3, 22-24 19/11/04

Great Western Road, Flat 3, 22-24 26/04/04

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Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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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 Great Western Road, Flat 3, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Ffion Simmons Unannounced Inspection 6th December 2005 11:00 Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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 Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 3, 22-24 Address 22-24 Great Western Road London W9 3NN 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 7289 5041 020 8964 5507 The Westminster Society for People with Learning Disabilities Christine Quantock Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Flat 3 is a purpose built, wheelchair accessible, first floor flat providing accommodation for six service users of either gender with a learning disability. The property is owned and maintained by Paddington Church Housing Association, and the care is provided by the Westminster Society for People with Learning Disability, a voluntary organisation. The home is located in a residential area of Westbourne Grove, close to shops and transport links. The home is part of a small residential block that includes a second registered care home and six flats for people with a learning disability who are living independently. Each person living in the home has their own bedroom. Communal areas, bathrooms and toilets are shared. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 11am and 15.30pm on the 6th December 2005. The inspector met with service users, staff and checked records. The inspector also observed care practices. What the service does well: What has improved since the last inspection? What they could do better: A total of nine requirements were set as a result of this inspection. Three of these requirements were set as immediate requirements as they potentially affect the health and safety of service users. They included the need for regular fire alarm checks to be performed, regular water temperature checks to be done and checks on the medication administration records (MAR) to ensure that they correctly reflect the needs of service users. Some gaps were noted in the MAR sheets and steps must be taken to ensure that the records are correctly maintained. There is a need for the home to ensure that service users’ care plans and risk assessments are up-to-date so that they fully reflect the needs of service users. Permanent management arrangements must be put in place and the permanently allocated person must register as the Registered Manager with the CSCI. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 6 The home’s Quality Assurance systems must include service users and quality of care must be regularly reviewed. 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. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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 Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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 the following standard(s): 5 Each service user has an individual written contract on their files outlining their rights and responsibilities with the home. EVIDENCE: There have been no changes to these standards since the last inspection. Each service user has an individual written contract of terms and conditions with the home outlining their rights and responsibilities. The contracts are available to each service user in their personal files and contains symbols and pictures. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 The service user care plans are person centred and include detailed information but they must be updated following care plan reviews to fully reflect the service users’ current needs. Risk assessments are thorough, but should be kept up-to-date to fully promote service users’ safety. EVIDENCE: The personal files of three service users were checked during the inspection. Each service user has an individual plan of care outlining their needs and wishes. The care plans are very detailed and person centred reflecting that service users are involved and that their wishes are sought. Daily logs are completed to document how service users are supported to meet their needs. The care plans of two service users had not been updated following their care plan review meeting and must be updated to reflect any changes. Two team members have completed multi-media training with the aim of supporting service user to make individual plans more accessible. Risk taking policies were on file for all three service users. The risk taking policies highlight potential risks and strategies for minimising risks. One of the risk taking policies is in need of updating and it is a requirement that this is done. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 10 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): 11, 13 Service users have a full programme of activities and have opportunities for personal development and for being part of the local community. EVIDENCE: When the inspector arrived at the home, three of the service users were at home relaxing and two were attending their day service. Service users living at flat 3 have a full programme of activities and opportunities for personal development. These are outlined in their care plans. Service users are also supported to be part the local community and during the afternoon of the inspection, one of he service users was supported to go out to a local coffee shop. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users’ personal care needs are well documented enabling staff to provide personal support in the way the service user prefers. There was good evidence of multi-disciplinary working. Staff should however review and archive old health care records to ensure that the files clearly illustrates recent input from the multi-disciplinary team. Medication is securely stored but some errors were noted in the medication administration records, and attention must be urgently given to ensuring the safe administration of medication. EVIDENCE: Service users’ personal care needs are well documented in their individual care plans and outline their abilities and preferences. The healthcare files of three service users were checked during the inspection. The records outlined that service users have access to the multi-disciplinary team including the GP, District Nurses, Continence Advisors, Physiotherapist and Occupational Therapist. The files contained a great deal of information about the input of the multi-disciplinary team. The information in some files were dating back to 2001. It is a recommendation that old information is archived appropriately to make the health care files more user friendly and less bulky. Medications are received mainly in blister packs, and are securely stored in a metal cabinet. The medication records of all six service users were checked during the inspection. Some errors were noted on the Medication Administration Records, which included gaps in the records. The MAR sheet of Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 12 one service user indicated that eye drops had been prescribed twice a day and another tablet to be taken once daily. There was a gap in the records for these two drugs. The Team Leader confirmed that these medications were not required by the service user. All MAR sheets must be carefully checked and must reflect accurately the medication to be administered to the service user. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 13 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, A good complaints system is in place enabling service users to voice their concerns. EVIDENCE: A copy of the home’s complaints policy is made available to each individual service user within their personal files. The policy makes good use of symbols and pictures. Service users are encouraged and supported to lodge a complaint and are encouraged to voice any concerns during house meetings. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 14 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, 30 Service users living at flat 3 benefit from a warm, homely, comfortable and safe environment. The home is clean and hygienic. Service users have access to the public transport and local amenities, which are located nearby. EVIDENCE: Flat 3 is a purpose-built, wheelchair accessible flat which accommodates six people. The security in the home is good with entry to the main building via entry phone system. CCTV cameras have been fitted to monitor the main entrance. A tour of the communal areas was undertaken during the inspection. The home is comfortable and homely and service users spent the morning of the inspection relaxing either in the main lounge or their bedrooms. One service user returned home from hospital in the afternoon and said that they were very happy to be home. There is a separate laundry room, which is situated away from the kitchen area. The laundry room has two washing machines and two dryers fitted. The home was clean and hygienic at the time of the inspection. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 15 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): 34, 35 The home’s recruitment policy ensures that all the necessary checks are undertaken on staff prior to them working with service users. This ensures that staff employed, are suitable to work with vulnerable adults. Staff have undergone training in safe working practices aiming to promote the health and safety of service users. EVIDENCE: The Society’s human resources department is responsible for ensuring that all pre-employment checks have been completed prior to staff commencing work. The checks include references and CRB and POVA checks. Application forms are completed and face-to-face interviews are conducted. The Team Leader confirmed that one of the service users had been on a recent interview panel. The staff training records were checked. The inspector noted that training had been undertaken in safe working practices since the last inspection including fire training, first aid training, food hygiene and manual handling. It is a recommendation that a system is developed to highlight when staff are due training updates in safe working practices. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 16 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, 42 The home’s Registered Manager has left her post since the last inspection and the post is currently being filled temporarily by another registered manager who works in the flat above. Steps must be taken to formalise these arrangements so that service users benefit from a consistently managed service. The home’s self-monitoring needs to be effective and include the views of service users. Shortfalls were noted in the health and safety systems in the home, which impacts on the home’s ability to maintain health and safety of service users. EVIDENCE: The Registered Manager/service manager of the home has left after a number of years in post. The post is currently being filled, temporarily by another registered manager who works in the flat above. This acting up post was initially for a three month period. Steps must now be taken to formalise these arrangements and ensure that the allocated person is registered with the CSCI as the Registered Manager. A Team Leader is in post to oversee the day-today running of the home. The Team Leader is very experienced and has worked for a number of years with the client group and is very aware of their needs. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 17 The Society is currently in the process of devising a satisfaction questionnaire that will be used to gain service users’ views about the service provided. The questionnaires should be implemented and the results of the questionnaires should be published. A service plan is in place for assessing the standards in the home against the National Minimum Standards. The audit should take place at least annually and a report of the findings should be made available to service user and the CSCI. Health and safety documentation was checked as part of the inspection. Some of the health and safety checks are not being completed as regularly as they should. An immediate requirement notice was left to ensure that water temperatures are measured weekly and the fire alarm is tested weekly. The inspector noted that staff had undergone training in safe working practices since the last inspection. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 18 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 x x x x 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 x 13 3 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Great Western Road, Flat 3, 22-24 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x DS0000010877.V271671.R01.S.doc Version 5.0 Page 19 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 YA6 Regulation 15 [2] Timescale for action Staff must ensure that the 01/03/06 individual plans are reviewed at least every six months with the input of the service user and representatives where apprioriate. Risk assessments must be 01/02/06 regularly reviewed to reflect the changing needs of service users. Staff must ensure that the 06/12/05 Medication Administration Records reflect the medication required by service users. Immediate Staff must ensure that there are 01/01/06 no gaps in the medication administration records. The Society must notify the 01/02/06 Commission of the permanent arrangements for replacing the Registered Manager of flat 3. The newly appointed manager 01/03/06 must complete a registered manager’s application with the CSCI’s Central Registrations Team. The Society must ensure that its 01/04/06 Quality Assurance system includes service users and their DS0000010877.V271671.R01.S.doc Version 5.0 Page 20 Requirement 2 3 YA9 YA20 13 [4] 13 [2] 4 5 YA20 YA37 13 [2] 39 6 YA37 CSA 2000 7 YA39 24 Great Western Road, Flat 3, 22-24 8 9 YA42 YA42 23 [4] 13 [4] representatives and that the quality of care is regularly reviewed. Staff must ensue that the fire alarm is tested weekly. 06/12/05 Immediate Staff must ensure that weekly water temperature checks are 06/12/05 undertaken. Immediate 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 YA19 YA35 Good Practice Recommendations The Manager should consider reviewing the filing system of service users’ health records and archive old records. A system should be developed to highlight when staff are due training updates in safe working practices. Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Great Western Road, Flat 3, 22-24 DS0000010877.V271671.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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