Inspection on 18/09/07 for Heather Lane, 74

This inspection was carried out on 18th September 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heather Lane, 74 05/12/06

Heather Lane, 74 24/01/06

Heather Lane, 74 28/10/04

Heather Lane, 74 01/07/04

Heather Lane, 74 05/11/03

Heather Lane, 74 23/05/03

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Heather Lane, 74 Yiewsley Middlesex UB7 7AU Lead Inspector Ms Jean Bovell Key Unannounced Inspection 18th September 2007 11:00 Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heather Lane, 74 Address Yiewsley Middlesex UB7 7AU 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) 01895 421947 tanners@lifeopportunitiestrust.co.uk www.lifeopportunitiestr Life Opportunities Trust Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2006 Brief Description of the Service: 74 Heather Lane is a registered home that offers support for three people with learning difficulties. The building is owned and maintained by Shepherds Bush Housing Association. Life Opportunities Trust manages the service. The house is situated in a residential area of Yiewsley with the shopping centres of Uxbridge and West Drayton accessible by public transport. The ground floor has a large lounge, kitchen, one bedroom and a shower room. The first floor consists of two bedrooms, a bathroom and a sleeping-in room/office. There is an attractive rear garden. There are currently three residents at the home and the staff team consists of a Manager Designate, one Senior Support Worker and two Support Workers. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11:30am and 4:00pm on Tuesday 18th September. A Senior Support Worker was initially present. The Inspector was informed that the Manager Designate would be covering the afternoon/evening/sleep-in shifts and that all three residents were at the day centre. During the course of the inspection: the home’s records, documents, policies and procedures were viewed. A tour of the building was undertaken and observations were made. The requirements that were made at the last inspection and all key Standards were examined. The Inspector received appropriate assistance from a Senior Support Worker and also the Manager Designate following her arrival at the home. What the service does well: What has improved since the last inspection? Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 6 Three requirements were made at the last inspection and all had been complied with. Specifically, staff recruitment files were available for inspection. Tests for Legionella had been carried out. Quality assurance for reviewing the service had been undertaken and summarized. 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. The summary of this inspection report can be made available in other formats on request. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records relating to three residents were examined and it was evidenced that separate needs and aspirations of people were appropriately assessed prior to admission. EVIDENCE: Personal records regarding three residents were examined and reflected that referrals to the home were made by Social Workers based in Community Teams for People with Learning Difficulties. Life Opportunities Trust assessment forms had been completed as required and submitted at the point of referral. Subsequent assessments were carried out by the home and initiated with a visit to prospective residents. It was indicated that social workers, relevant healthcare professionals, relatives and prospective residents were involved in the process of assessing and determining the suitability of the home to meet separate identified needs and aspirations. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Separate care plans and risk assessments were viewed and found to be satisfactory. It was also indicated that people were able to make decisions regarding their daily living routines. EVIDENCE: Care plans that had been drawn up in relation to three residents were viewed. It was evidenced that separate personal, health care, social and educational needs had been assessed. Actions and goals were put in place and action plan progress sheets were being completed. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 10 Assessments of risk relating to specific activities identified within care plans had been undertaken and included climbing stairs, opening windows, showering, vacuuming and cooking. The Inspector was informed by a Senior Support Worker that people made decisions regarding meals, activities, what they wore, make-up/hairstyles and when they retired at night. People were also able to make personal purchases such as magazines, newspapers, toiletries and items of clothing. Residents were involved in compiling individual journals, written in a format suitable to meeting their needs and titled ‘About the Person – Life and Choices’. It contained an account of daily routines, day centre attendance and activities. Colourful photographs of the respective resident and significant people such as relatives, advocates, day centre staff and key workers were also included. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records are indicative of people being able to participate in activities in the community and assist with housekeeping tasks as appropriate. Contact with relatives and advocates are being maintained. Varied and nutritional meals are provided. EVIDENCE: A Senior Support Worker reported that all residents attended the day centre on weekdays. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 12 The records indicated that people attended religious clubs or may visit relatives on weekends. There were no indicators that people were being regularly supported in the community, particularly on weekends. However, a Senior Support Worker reported that people were supported during annual holidays arranged by the home and that a weekend away trip had been planned for one resident. Residents also visited the theatre, were taken for pub lunches, accompanied staff during weekly food shopping and that a boat trip on the canal had been organised during the summer. Three people were at the day centre at the time of the inspection. An open visiting policy was in place and records were reflective of residents being in regular contact with relatives and/or advocates. It was evidenced on care plans that residents participated in housekeeping tasks such as tidying bedrooms, vacuuming, dusting and gardening. A variety of food was stored in kitchen cupboards, refrigerator and freezer, and fresh fruit was accessibly placed. A Senior Support Worker confirmed that those capable prepared vegetables, drinks and made packed lunches. Snacks and drinks were readily available to everyone. The home does not employ a cook but support staff prepares at least one cooked meal each day. The menus were viewed and wholesome/varied meals were reflected. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The records indicated that received personal care as required and that their physical and emotional health care needs were being met. The home’s policy and procedures on medication are satisfactory. EVIDENCE: The personal needs of people were identified within individual care plans and it was indicated that some people required assistance with their daily routine. A Senior Support Worker confirmed that all personal care tasks were carried out in privacy within bedrooms or bathrooms but that all residents were able to choose what they wore, make-up and hairstyles. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 14 Separate health care needs were being assessed and indicated that people received access to healthcare professionals as required and were accompanied to medical appointments. Life Opportunities Trust policy and procedures on medication were in place and the records were indicative of staff training on medication being delivered. Medication was contained in blister packs, securely stored and daily temperatures were being taken. Medication Administration Sheets were viewed and were accurately documented and appropriately signed. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was in a place and appropriately detailed. The records were indicative of people being satisfactorily protected from abuse. EVIDENCE: The complaints procedure was clearly written and illustrated in a format suitable to meeting the needs of the people who use the service and accessible to their relatives and/or advocates. The complaints book was viewed and reflected that no complaints had been made to the home since the last inspection. Life Opportunities Trust policy and procedures on abuse were in place and records were indicative of staff training on the Protection of Vulnerable Adults being delivered. Incident and accident records were satisfactory. The home does not hold financial responsibility for residents but benefit allowances are kept safely by staff, on behalf of residents. Separate financial Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 16 records in relation to personal allowances/expenditure were inspected and no discrepancies were identified. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is well maintained, safe and homely. EVIDENCE: The communal areas at the home are spacious, comfortably and appropriately furnished and suitable for shared and/or individual activity. Framed photographs of residents were on display. The garden was tidily kept and accessible to residents. There were no issues regarding the laundry. The environment was well maintained, bright, airy and homely. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff records were inspected and reflected that care staff were appropriately trained and qualified for meeting the needs of residents. Staffing levels during waking hours, particularly on weekends are inadequate. Life Opportunities Trust policy and procedures on medication are satisfactory. EVIDENCE: It was reflected on training records that three members of the care support staff team had achieved levels 2 or 3 National Vocational Qualification. It was also indicated that all care staff received induction and mandatory training and that annual refreshers were delivered. Recent staff training included Protection Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 19 of Vulnerable Adults, Dementia Awareness, Epilepsy and Challenging Behaviour. The Manager Designate confirmed that four support workers, including a Senior Support Worker, a part-time worker and the Manager Designate were employed at the home but there was one vacancy at the time of the inspection. Concerns regarding insufficient staff numbers for ensuring that residents are supported in the community, particularly on weekends, were raised with the Manager Designate. She confirmed that these issues would be appropriately addressed. The Registered Manager also acts in the capacity of support worker and covered regular day/night duty on weekdays. The rota was reflective of one support worker being on duty during waking hours and one sleep-in cover at night. Staff recruitment files were inspected at random and contained all required documents. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager Designate is suitably experienced and qualified. Quality assurance is being appropriately undertaken. The health and safety of people who use the service are being satisfactorily protected. EVIDENCE: Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 21 The Manager Designate had been an employee of Life Opportunities Trust for fourteen years and has occupied her present position for twelve months. She is currently receiving training on the Registered Managers Award. It was evidenced on documents viewed that effective quality assurance for reviewing the service had been undertaken and appropriately summarized. All health and safety checks including those for fire safety, portable appliances, gas maintenance and water temperature were up to date. Fire drills were being regularly undertaken and environmental risk assessments had been carried out. The records were reflective of staff training on fire safety, food hygiene and moving and handling being delivered. Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 27 28 29 30 3 3 X 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000027090.V349123.R01.S.doc 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Heather Lane, 74 Score 3 3 3 X 3 X 3 X X 3 X Version 5.2 Page 23 N0 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 YA33 Regulation 18(1)(a) Requirement The Registered Person must make sure that the home is appropriately staffed, particularly on weekends, to ensure that residents are able to participate in separate activities within the community. Timescale for action 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heather Lane, 74 DS0000027090.V349123.R01.S.doc Version 5.2 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. 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