Inspection on 17/01/06 for Great Western Road, Flat 4, 22-24

This inspection was carried out on 17th January 2006.

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

Great Western Road, Flat 4, 22-24 29/05/07

Great Western Road, Flat 4, 22-24 06/09/06

Great Western Road, Flat 4, 22-24 12/07/05

Great Western Road, Flat 4, 22-24 23/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Great Western Road, Flat 4, 22-24 22-24 Great Western Road London W9 3NN Lead Inspector Ffion Simmons Unannounced Inspection 17th January 2006 11:20 Great Western Road, Flat 4, 22-24 DS0000010878.V278799.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 Great Western Road, Flat 4, 22-24 DS0000010878.V278799.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. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Great Western Road, Flat 4, 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 4752 020 8964 5507 The Westminster Society for People with Learning Disabilities Miss Michelle Hart Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Flat 4 is a purpose built, wheelchair accessible, second floor flat that is registered to provide care for 6 people with learning disabilities. The property is owned by Paddington Churches Housing Association and the care is provided by the Westminster Society for People with a 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 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over six hours. The inspector had the opportunity to spend time with five of the six service users living at the home and observed some care practices. Records and documentation were also checked during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 6 Five requirements were set following this inspection visit. One of the requirements is being repeated from the last inspection. There is a need to ensure that all staff are up-to-date in their training in safe working practices. Consideration should be given to developing a system for highlighting when staff are due training updates. Training needs analysis should also be completed on all staff. Although the content of the complaints records have improved, the overall process/format of recording complaints should be reviewed. The service users’ healthcare records must be kept up to date and consideration should be given to archiving old information. Steps must be taken to ensure that the quality assurance systems in the home are improved. 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 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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): 1,2,4 There is a good level of up-to-date information available for all interested parties about the home’s services. This assists service users to make an informed choice about choosing their home. The service users’ needs are assessed prior to admission and service users have the opportunity to visit the home prior to moving in. EVIDENCE: The home has a statement of purpose and service user’s guide, which is available to the service users, prospective service users and any other interested party. The statement of purpose has been updated since the last inspection to include details of the new service management structure and to include the experience and qualifications of the current manager. A new service user has been admitted to the home since the last inspection. The service user moved from another of the Westminster Society’s registered care homes. Both staff teams worked together to co-ordinate the move, which included visits to the home leading up to overnight stays. This enabled the staff team to further assess the needs of the service user and establish the suitability of the placement. This also enabled the service user to meet and become familiar with the environment, the staff and other service users at the home. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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): 6,7,9, The individual care plans of service users are detailed and person centred, and they clearly outline service users’ needs. The plans also reflect that service users are supported to make their own choices and decisions about their lives. Clear and up-to-date risk assessments are in place for identifying and minimising the risks to service users’ safety. EVIDENCE: The individual care plans of three service users were checked during the inspection. The information within the plans is very comprehensive and outline their main care needs including health and social care needs. The plans are person-centred and demonstrate that the service users’ wishes and feelings have been taken into account. The individual care plans have either been recently updated or are due to be updated within the month. Since the last inspection, staff have supported a service user to update their individual support plan with the use of pictures. The service user led the care review meeting and the plan fully reflects the service user’s own wishes and aspirations. The Manager commented that this process had been very effective and the team are now planning to introduce this format of recording needs and wishes of other service user within the service. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 10 Each of the service users had an updated risk taking policy on file. The risk taking policies highlight potential risks and strategies for minimising risks. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15, 16, 17 Service users are supported to maintain personal and family relationships and are provided opportunities to be part of the local community. EVIDENCE: Details about the service users’ personal and family relationships are outlined in their individual plans. There was evidence within the files, that service users are supported to maintain relationships with their families and friends. Service users have access to day care services and each of the service users living at the home have a full programme of activities which enable them to spend time with friends and be part of the local community. Daily routines were observed to be flexible and service users were being offered choices. Each service users’ abilities and housekeeping responsibilities are highlighted in individual plans. Service users have full use of the home’s communal areas and service users’ privacy is respected. One of the service users has their own menu in pictorial format and an allocated day for going shopping for food. The other service users are offered a choice from a monthly menu. Healthy eating guidelines are outlined within Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 12 service users’ individual files. Mealtimes were seen to be flexible, depending on service users’ daily schedule. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Service users’ needs are well documented and service users’ privacy is respected. The medication is well managed and service users have access to the multi-disciplinary health care team. Some of the health care records were not up-to-date and old records should be archived. EVIDENCE: Service users’ needs, preferences and wishes with regards to personal care are outlined in their individual care plans. Same gender care is offered wherever possible and personal care is provided in private. There are separate health care records kept for each service user. These were seen during the inspection. There was evidence that service users have access to the multidisciplinary team including practice nurses, community nurses, GP’s, Chiropodist and opticians. Some of the information on file was not current and the health records must be kept up-to-date and accurate. It is also a recommendation that the old information should be archived to make the files easier to read and use. Medication is dispensed from the pharmacy mainly in blister packs. The medications are then stored in a locked metal, wall-mounted cabinet, which is within a locked store cupboard. The medication administration records of all six service users were checked during the inspection and they were found to be well completed. There are no service users currently self-medicating and Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 14 no controlled drugs are currently in use. Codes used when medication is not administered are defined and is an improvement from the last inspection. The team have worked on gathering the wishes of service users regarding death and terminal care, which is also an improvement from the last inspection. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, The home’s complaints policy and procedure is accessible to service users. Service users are supported to make a complaint when unhappy with aspects of the service. The overall format of recording complaints and subsequent actions should be reviewed. EVIDENCE: The home’s complaints procedure is made available to service users in their service user’s guide. There was evidence that service users are supported to voice their concerns when they are not happy with any aspect of their care. Where service users have lodged a complaint, the complaints records demonstrated that staff have taken their views seriously and acted on their concerns. Although the complaint records demonstrate what action has been taken, it is a recommendation that the home looks at the overall process of recording complaints. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Service users’ home was clean and hygienic at the time of the inspection. EVIDENCE: The home was clean and hygienic at the time of the inspection. There is a separate laundry room equipped with two washing machines and two dryers. Since the last inspection, the carpet in the communal lounge has been deep cleaned and steps are being taken to ensure that this is carried out regularly. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 17 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, 34, 35 A high percentage of the staff team have the NVQ qualifications for caring for the group of service users. New staff are inducted into their role. Steps must be taken to ensure that all staff are up-to-date with training in safe working practices. This is crucial for promoting the health and safety of service users. The recruitment practices are thorough and the staff rotas are flexible. EVIDENCE: A high percentage of the staff team are qualified to NVQ level 2 or above. Newly employed staff have attended induction training and mandatory training, which include fire safety training, manual handling, food hygiene, first aid, medication and learning disability awareness training. The training records have improved since the last inspection, but the home would benefit from producing an individual training needs analysis for staff. Some staff whom have worked at the home for longer are not up-to-date with their training in safe working practices. Steps must be taken to ensure that staff complete the necessary mandatory training updates. The Society’s human resources department is responsible for ensuring that all pre-employment checks are completed on staff prior to staff commencing work. Since the last inspection, a written confirmation is sent from the human resources department to the home manager confirming that all checks have been completed and are satisfactory. These checks include reference checks, a CRB check and checks against the Protection of Vulnerable Adults list. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 18 The staff rotas were checked during the inspection. The rotas demonstrate that there is a minimum of two staff on duty at any one time during the day. There is a waking night staff on duty and an on-call member sleeping in the home during the night. The number of staff on duty is flexible to meet the needs of service users, for example for supporting service users to their health appointments and activities outside the home. The Manager explained that a mid shift of 10am until 6pm is used at week-ends to enable service users to enjoy leisure activities at the week-ends. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 19 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 is managed by a registered person, who understands the needs of the current service users. The home’s quality assurance systems must be improved to ensure that they are effective in assessing the quality of the service offered and involve service users. EVIDENCE: Since the last inspection, the manager has successfully registered as the manager with the Commission. The training records indicate that she undertakes periodic training to update her skills and knowledge and has recently attended training in Care Standards Act, managing change, team development and disciplinary investigations. The Manager has an NVQ level 4 qualification and a degree in Social Sciences and Welfare studies. Visits on behalf of the registered provider take place, but the Commission does not always receive copies of the reports. On the occasions that the CSCI has received reports, they are brief and not sufficiently detailed. The home’s last audit was in July 2004 and the current audit tool has been suspended and is being reviewed. The service user quality assurance questionnaires are due to be introduced very shortly. The Society must ensure that the quality Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 20 assurance systems are more robust and meet the National Minimum Standards and the regulations. Some of the home’s health and safety documentation was checked during the inspection. There was evidence that regular fire alarm tests and fire drills are regularly performed. Water temperatures in the home are regularly tested and were seen to be within safe temperatures. There is a need to ensure that all staff are fully up-to-date with training in safe working practices. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 21 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X 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 2 3 3 3 X 2 X X 2 X Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 22 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 2 Standard YA19 YA39 Regulation 24 24 Timescale for action The health records must be kept 01/03/05 up-to-date and accurate. The home’s quality assurance 01/05/06 systems must be effective and must meet the National Minimum Standards and the regulations. This includes consulting with service users on the quality of the service and continuous selfmonitoring including at least an annual audit. The reports of the visit on behalf 01/03/06 of the registered provider must provide sufficient details about the standards of care provided at the home and must fulfil the requirements of regulation 26. The reports of visit on behalf of 01/03/06 the registered provider must be sent to the Commission. Staff must be up-to-date with 01/05/06 their training in safe working practices including infection control, fire, health and safety, food hygiene and manual handling. Previous timescale of 01/10/05 not met. This is a repeat requirement. DS0000010878.V278799.R01.S.doc Version 5.1 Page 23 Requirement 3 YA39 26 4 5 YA39 YA35YA42 26 13 [3] [4] [5] [6] Great Western Road, Flat 4, 22-24 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 3 Refer to Standard YA19 YA22 YA35 Good Practice Recommendations The Manager should consider reviewing the filing system of service users’ health records and archive old records. The overall process/format of recording complaints should be reviewed. A system should be developed to highlight when staff are due training updates in safe working practices. Individual training needs analysis should be completed on all staff. Great Western Road, Flat 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 24 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 4, 22-24 DS0000010878.V278799.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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