Inspection on 17/02/06 for Hartley House

This inspection was carried out on 17th February 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartley House 15/01/07

Hartley House 25/07/06

Hartley House 05/07/05

Hartley House 07/10/04

Hartley House 06/05/04

Hartley House 07/01/04

Hartley House 12/06/03

Similar services:

Agar Grove & St Augustine`s Alcohol Treatment & Rehab

Herbert Street

Haven (The)

Charis

Brook Drive, 124

Rugby House Project

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

CARE HOME ADULTS 18-65 Hartley House 31 Madeley Road Ealing London W5 2LS Lead Inspector Mr Gavin Thomas Unannounced Inspection 17th February 2006 2:30pm Hartley House DS0000027732.V278389.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 Hartley House DS0000027732.V278389.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. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hartley House Address 31 Madeley Road Ealing London W5 2LS 0208 997 0022 0208 810 5384 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) Turning Point Limited Care Home 12 Category(ies) of Past or present alcohol dependence (0) registration, with number of places Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate a maximum of 3 service users over the age of 65 years including service users resident in the home prior to their 65th birthday. 5th July 2005 Date of last inspection Brief Description of the Service: Hartley House is a well - established service offering rehabilitation for the maximum period of six months, for people who have an alcohol dependency and wish to adopt an alcohol free lifestyle. The establishment is owned and managed by Turning Point. Turning Point is a national social care charity providing a range of community based projects for people recovering from alcohol and drug addictions, mental illness and learning disabilities. Turning Points first service was opened in 1964. Hartley House accommodates a maximum of twelve men or women. The service provides group therapy and one to one key work sessions. Emphasis is also placed on service users participation in the community. The home is staffed from 9am - 5pm Monday to Friday. Service users can contact staff outside of these hours on a free phone number. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of three hours. During this time, the Inspector met with the Acting Manager, Project Workers, service users and ex – service users who were also visiting the home. A selection of records were also sampled. Staff and service users were preparing the home for building works, which were due to commence on 20/02/06. One service user said that the quality of service at Hartley House exceeded their expectations. The service user said they feel much more healthier and more focused on improving the quality of their life since moving to Hartley House. One Project Worker was of the opinion that the home does well in applying the rehabilitation programme in meeting service users individual needs. Nine service users were admitted to the home at the time of this inspection. The home intends to leave two beds empty until such time when refurbishment work is complete. The majority of service users were away spending the weekend with their respective families at the time of this inspection. Currently, this service does not have a Registered Manager. An experienced Project Worker has been appointed as Acting Manager until such time when a Manager is appointed. What the service does well: Hartley House provides a dedicated and professional service for people recovering from alcoholism. The Acting Manager and the staff team are doing very well in maintaining a good quality service in the absence of a permanent Manager. The home does well in supporting service users to complete the rehabilitation programme. Only two service users relapsed and were unable to complete the programme since the last inspection. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hartley House DS0000027732.V278389.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 Hartley House DS0000027732.V278389.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): 5 The content of the license agreement was very clearly set out and comprehensive. EVIDENCE: The contract between the home and a service user is known as the license agreement. The license agreement is issued to service users on their induction day. The license agreement is signed and dated by the service user and a representative for Turning Point. Service users are issued with a copy of the license agreement. A copy is also retained by the home. The Acting Manager confirmed that all service users were in receipt of a copy of the license agreement. One service user spoken to confirmed this. Hartley House DS0000027732.V278389.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): 9 Good systems were in place for identifying and managing risks with service users. EVIDENCE: Risk assessments were in place for all service users. Risk assessments are completed with service users within the first two to three days of their admission to the service. Risk factors take into account service users health, behaviour, self – harm, drugs and negligence. The risk assessment process includes possible triggers and an action plan for risks identified. A risk management summary is also included in the risk assessment. The timescales for reviewing risk assessments with service users are as follows: • Three weeks. • Two months. • Four months. • Six months. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 10 Completed risk assessments examined were very specific and were linked to the service user’s goals and outcomes for their duration of their stay at Hartley House. All reviews were well documented. Hartley House DS0000027732.V278389.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): 16 Effective systems were in place for consulting with the service users. EVIDENCE: All service users are required to contribute to the running of the home. This includes cooking, shopping and maintaining the upkeep of bedrooms and communal rooms. A domestic rota is agreed with all service users every Friday. Service users’ contributions to household tasks, takes into account any other commitments they may have. Rules on smoking and alcohol are included in the license agreement. One Project Worker confirmed that service users receive their post unopened. All service users are required to attend community meetings, which normally take place in the mornings during weekdays. Service users are also required to be present for lunch. There are exceptions if service users have other commitments. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 12 Although the home promotes choice and independence, service users are required to demonstrate that they use their own time constructively. One service user was of the opinion that the programme at Hartley House is well balanced, enabling service users to learn from the group meetings, assess their progress via key worker sessions and spending time re – establishing a purposeful place in the community. Service users are prohibited from leaving the home on their own for the first two weeks following admission. Prospective service users are made aware of this prior to admission. Room checks are carried out by two staff at all times. Service users are given a twenty – four hour notice prior to routine room checks being carried out. Staff will enter service users bedrooms on discretion at other times if necessary, with little or no warning. These procedures are included in the service user handbook. Hartley House DS0000027732.V278389.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): 19 The health needs of service users are well met with evidence of good multi disciplinary work taking place in accordance with individual service users needs. EVIDENCE: The home is not suitable for service users who may have a sensory impairment or a disability and unable to manage stairs or require adapted facilities. The home will not accept prospective service users who are prescribed psychiatric drugs or unable to self medicate. The home is not registered to accept service users who require nursing care. Health needs are thoroughly explored with prospective service users prior to admission. Service users either register with a local GP or retain registration with their own GP. This is often dependent on the service user’s health needs prior to moving to Hartley House. One Project Worker explained that service users are supported to access specialist health care treatments or to attend out patient appointments. Health related matters were included in service users care plans. Service users are supported and encouraged to live a healthy and alcohol free lifestyle. This includes a healthy diet, exercise, attending hospital appointments, addressing Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 14 their psychological and emotional needs and setting realistic goals for the future. The Project Worker said there were no known serious health concerns with any of the service users living in the home at the time of this inspection. One service user informed the Inspector that they were feeling much healthier both mentally and physically, since moving to Hartley House. Hartley House DS0000027732.V278389.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 has a satisfactory complaints procedure in place. EVIDENCE: A complaints procedure was in place. There have been no changes to this procedure. The Acting Manager confirmed that the home had not received any complaints since the last inspection. The complaints procedure is included in the service user handbook. Hartley House DS0000027732.V278389.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): 24 Service users are to be highly commended for their contributions in maintaining the cleanliness and upkeep of the home. The refurbishment will significantly improve some of the facilities as stated below. EVIDENCE: The home is situated in a residential setting and in keeping with local ambience. It is a large Victorian house and very well kept. Some of the features and provisions include a large billiard table come dining table, a non smoking lounge, meeting/quiet rooms and a large enclosed rear garden, most of which is laid to lawn. The home is ideally located for easy access to public transport routes, shops and other amenities. Ealing Broadway is within walking distance from the home. The home was very clean and well presented. A guided tour of the home was conducted with a Project Worker. Areas of the home inspected were the kitchen, dining room, lounge, consultation/quiet rooms, bathrooms, toilets and a vacant twin bedroom. The twin bedroom was fitted with a curtain screen, two washbasins and sufficient storage space for two people. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 17 A major refurbishment programme was due to commence on 20th February 2006 and expected to be completed by 7th May 2006. The work will consist of: • Removal of existing kitchen and re-fitting of new units, wall tiles and flooring. • Removal of two baths and refitting of two new baths. • Redecoration of all bedrooms, communal areas and office. • Repair of rear garden wall. • Re – pointing and repair of brickwork to the front of the house. The Acting Manager supplied the following details to the Commission for Social Care Inspection prior to this inspection. • Refurbishment programme as above including timescales for each phase of the programme. • Contingency plan for relocating essential food and beverage facilities and dining/food arrangements. • Details of the approved contractor to undertake the work. • Confirmation that all service users and their care managers have been consulted on the refurbishment programme. The Acting Manager confirmed that where possible, service users currently living in the home have been included in selecting colour schemes for bedrooms and communal rooms. Two service users were assisting staff to prepare the kitchen in readiness for work to take place. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 Staff are well supported and supervised. EVIDENCE: One Project Worker confirmed that they attend formal one to one supervisions on a monthly basis. Completed records for recent supervisions were available for inspection purposes. The Project Worker also confirmed that they have an annual appraisal of their work. In addition to formal one to one supervisions, an independent professional provides clinical supervision fortnightly. The Project Worker gave very positive feedback on the formal one to one supervisions and group supervisions with the independent professional. Hartley House DS0000027732.V278389.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): 42 Overall health and safety systems were in place and well maintained. However, some of the findings on this inspection indicated that specific processes and safety reviews must be acted upon. EVIDENCE: Health and safety policies and procedures were in place. Health and safety systems were also observed during a guided tour of the premises. In the last year, staff completed the following training: • Fire safety. • Food hygiene. • First Aid. • Health and safety. A range of health and safety records were examined as follows: • Gas appliance tests. • Electrical appliance tests. Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 20 • • • • • Fire safety records including fire drills, fire safety checks and fire appliance tests. Fire risk assessments. Generic health and safety assessments. Record of hot water temperatures. C.O.S.H.H risk assessments. The fire risk assessment was generated in 2003. A review of this assessment was not available. The fire risk assessment must be reviewed to ensure that the contents are still relevant. In accordance with the record of hot water temperatures, the temperature of hot water discharged from one shower was 61.5 degrees Celsius. This temperature is too hot. Action must be taken to reduce the temperature of hot water to the recommended temperature of 41 degrees Celsius. The home must also take action to ensure that an appropriate mixer valve is attached to this shower. In light of this finding, it was strongly recommended that a survey is carried out to ensure that mixer valves are fitted to all bathing and showering facilities and to ensure that the temperature of hot water discharged from all bathing and showering facilities is within a safe range. The C.O.S.H.H risk assessments did not take into account cleaning products including bleach, which are stored in an unlocked cupboard under the staircase and cleaning products left exposed in bathrooms. Action must be taken to address these findings. Cabinets should be considered for the storage of cleaning products, which are currently left on the sides of baths. The laundry door is also a designated fire door and fitted with an automatic closing device. The closing device was broken at the time of this inspection and the door was propped open with a laundry basket. This was not judged to be good practice. Arrangements must be made for the closing device to be fixed. Staff have not undertaken any training in moving and handling. Although staff explained that they do not physically support service users, moving and handling training should be considered for other elements of the work they under take. Hartley House DS0000027732.V278389.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 x 2 x 3 x 4 x 5 3 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 3 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 3 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 x 13 x 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x x x x x x 2 x Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 22 No 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 YA42 YA42 Timescale for action Reg The fire risk assessment must be 30/04/06 23(4)(a) reviewed to ensure that the contents are still relevant. Reg Action must be taken to reduce 31/03/06 13(4)(c) the temperature of hot water, which is currently discharged from one shower at 61 degrees Celsius. Reg The C.O.S.H.H risk assessments 31/03/06 13(4)(c) must take into account cleaning products including bleach, which are stored in an unlocked cupboard under the staircase and cleaning products left exposed in bathrooms. Reg Arrangements must be made for 31/03/06 23(4)(c)(i) the automatic closing device on the laundry door to be repaired. Regulation Requirement 3 YA42 4 YA42 Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 23 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 YA42 Good Practice Recommendations A survey should be carried out to ensure that mixer valves are fitted to all bathing and showering facilities and to ensure that the temperature of hot water discharged from all bathing and showering facilities is within a safe range. Cabinets should be considered for the storage of cleaning products kept in bathrooms. Moving and handling training should be considered for the staff team. 2 3 YA42 YA42 Hartley House DS0000027732.V278389.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Hartley House DS0000027732.V278389.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!