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Inspection on 30/11/07 for Kingsway, 83a

Also see our care home review for Kingsway, 83a for more information

This inspection was carried out on 30th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Staff care for people who use service in a courteous and professional manner. There is a very homely atmosphere throughout, plus service users bedrooms are very personalised. Peoples choices are respected and they are encouraged to maintain as much individuality and independence as they are able, with staff support. People are encouraged to be a part of the local community and also attend day centres. Visiting is encouraged to keep in touch with family and friends. People who use the service are involved in the formulation of menus. Medications are well managed at the home. Systems are in place for effective quality assurance.

What has improved since the last inspection?

The home is now able to evidence that care plans are being reviewed. The home environment has been improved with the purchase of new equipment and carpeting on the ground floor.

What the care home could do better:

LOT has not as yet been successful in recruiting a manager for the home. The home has therefore been without a permanent manager for over 2 years. Action must be taken as a priority to address this. Training must be reviewed to ensure that all staff are receiving mandatory training in health and safety and the required induction standards. Health and Safety records must be reviewed to ensure the efficiency of fire extinguishers, and gas safety.

CARE HOME ADULTS 18-65 Kingsway, 83a Hayes Middlesex UB3 2TX Lead Inspector Susan Woolnough-Singh Key Unannounced Inspection 30th November 2007 10:30 Kingsway, 83a DS0000027068.V348822.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 Kingsway, 83a DS0000027068.V348822.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. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingsway, 83a Address Hayes Middlesex UB3 2TX 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 8813 7828 kingsway@lifeopportunitiestrust.co.uk lifeopportunitiestrust.co.uk www.lifeopportunitiestr Life Opportunities Trust Mrs Alison Hill Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th October 2006 Brief Description of the Service: 83a Kingsway provides accommodation and personal care for three female adults and one male adult, each with learning disabilities. The home is registered for four placements. The home is a detached house in a residential area of Hayes. It is close to local amenities and transport links. Shepherds Bush Housing Association owns the building and the organisation Life Opportunities Trust (LOT) provides the care. The environment is homely and comfortable. There is a front and rear garden. The front garden has grass and flowerbeds and the rear garden is mainly laid to lawn. There is a small patio area. The home aims to provide a range of high quality services for people for learning disabilities, which reflect and respect their individuality and wishes. The home seeks to promote active participation in the local community. The fees are currently £803.96 per week. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of 83 Kingsway took place on 30th November 2007 between 10.30 am and 4.30 pm. All of the Key National Minimum for adults were assessed apart from standard 34 (recruitment) There has been no change since the last inspection to the group of people who live at the Kingsway. On arrival three people were at their day placement and one person was preparing to go out swimming with a member of staff. Three staff were on duty, one of whom had slept in and was due to finish her shift. The Acting Manager was not on duty; therefore the Inspector was unable to view recruitment records. The Inspector carried out a tour of the home, and examined care plans, medication records, financial records, management records, administration records and maintenance. The Inspector met with three people who use the service and was able to talk with one of them. An Annual Quality Assurance Assessment had been completed and forwarded to the Commission for Social Care Inspection prior to the visit. What the service does well: What has improved since the last inspection? The home is now able to evidence that care plans are being reviewed. The home environment has been improved with the purchase of new equipment and carpeting on the ground floor. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kingsway, 83a DS0000027068.V348822.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 Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive a Needs Led Assessment prior to moving into the home. EVIDENCE: The home is registered for 4 service users and the last admission was in April 2005. Therefore there have been no new admissions since the last inspection and therefore no new pre-admission assessment documentation to view. Information on the Annual Quality Assurance document verified that a full assessment would take place of any person wishing to move into Kingsway, and that re-assessment takes place to keep up to Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place for each person who uses the service; these generally give a clear picture of their needs. Additional information is required for one plan. People who use the service are encouraged to make daily choices although guidance is given where necessary. Risk assessments have been carried out, thus identifying and minimising risks to service users. EVIDENCE: All of the care plans and risk assessments for people living at Kingsway were examined. These were comprehensive and gave a good picture of each person and their needs. The care plans in place were very detailed, covering all aspects of daily living. Areas covered in the care plan were special needs with Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 10 communication; leisure time, likes and dislikes, areas of health to be monitored, dietary requirements and contact with family and friends. The care needs of one person were discussed in detail with a member of staff. Professional support from an external professional had been sought and guidance given on the management of some behaviours. The Inspector, from this discussion ascertained that some staff needed clear guidance to increase their confidence. This was not reflected in the Care Plan. The care plan needs to include consistent strategies for working with people, where this additional information is necessary. Risk assessments had been completed which enabled people to have a degree of independence for example in managing their own money and risks to personal safety. The Inspector was able to observe that people are enabled to make their own decisions and that advice and support is also given as appropriate. Meetings are held for people who use the service once a month minutes of these were viewed. Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to participate in day services and activities in the community. People’s independence is encouraged within their ability, and family links are good. The menu provides a varied and balanced diet and people’s preferences are considered. EVIDENCE: People who use the service attend day a centre during the week, one person attends a careers development centre and an education centre. People who use the service have a daily routine part of which is being involved in tasks in the home and using facilities in the local community. On the day of the inspection one person with the encouragement of staff was being assisted to Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 12 tidy his/her bedroom and was then taken swimming and out shopping. The action plan, which formed part of one-person care plan, indicates that the person is being encouraged to become more assertive and improve in confidence. The Inspector spoke with one person who was keen to show his/her possessions and bedroom. Each service user has an individual room and is provided with a key to lock the door should they wish to use it. From observation it was evident that staff communicate well with people who use the service. People who use the service have links with family and friends. The Menu was seen, this covered breakfast, lunch and the evening meal. The evening meals mainly consisted of British food and pasta dishes. There is a roast dinner on Sundays. The member of staff spoken with said that peoples’ food preferences are know and catered for. The Inspector was also able to view the minutes of the residents meetings; the menu had been discussed and preferences had been voiced. Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are encouraged to look after their own personal care and assistance is given when required. People’s health care needs are identified and monitored although in one case records need to be updated. Medications are generally well managed at the home, although improvements need to be made to the format of the medication administration record. EVIDENCE: People’s independence is respected, and they are encouraged to carry out as much of their personal care as they are able, with staff available to assist as required. Moving and handling assessments have been completed; at the present time people who use the service do not require assistance in this area. The Health records of three people who use the service were examined. A record of Health Care Professional appointments is kept, this usually included Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 14 visits to the General Practitioner and Dentist. Where mental health care support is needed records show a relevant health care professional is monitoring the situation. People have health care action plans; one of these was dated 2006. A form is used to record health care professional visits; one person did not have a record that had been completed. Improvements need to be made with regard to health care recording. The Inspector viewed the medication records. The prescription medications are supplied in weekly blister packs. The medication administration record charts were fully completed, with receipts and administration of medication signed for. The medication record administration forms seen were very faint with the boxes corresponding to the date for staff to sign, barely visible. This needs to be addressed. Medications are securely stored. A list of staff and initials had been compiled. Instruction leaflets for the medications in use were available . Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures for complaints and for adult protection are in place. Staff training in the Protection of Vulnerable Adults has been planned for January 2008. EVIDENCE: The home has a complaints procedure for people who use the service an their families and a whistle blowing procedure for staff. These were not viewed on this occasion. The complaints book was seen it appeared that no complaints had been received since the last inspection. The recording of this was not available as it was not in the book having been somehow removed. The complaints record should be kept in a secure place where it cannot be tampered with. The staff training record indicated that Protection of Vulnerable Adults Training had not taken place for two staff although POVA training for all staff had been booked for January 2008. Clear records of people’s monies are maintained, to include all income and expenditure. Individual monies are held securely in the home. The Operations Manager for the area carries out a monthly audit of the service users monies, and signs to evidence this audit. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides homely and comfortable accommodation for people who use the service. EVIDENCE: At the time of the inspection the home was slightly disorganised due to the office being decorated and office items being stored in the lounge. Two requirements were made at the last inspection. These were for windows to be risk assessed and for the carpet on the ground floor to be replaced or repaired. Windows had been risked assessed and new carpet had been fitted in the lounge, stairs and hallway. People who use the service were able to show the Inspector their bedroom, rooms were personalised and reflected their interests. Each person has a pedestal wash hand basin in his or her room. The furniture provision in the bedrooms was suitable to meet the their needs. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 17 The home has one bath and one shower facility in place. There are two toilets and each bedroom has a wash hand basin. There is a spacious communal dining/sitting room. There is a table and six chairs in the dining section, and two sofas and a comfortable chair plus television, DVD, video and music players in the lounge section of the room. The kitchen is spacious enough for those who may wish to help with food preparation. New equipment has been purchased since the last inspection; this includes a cooker, dishwasher and flat screen television. The home was clean and tidy throughout. There is a laundry room with a washing machine and tumble dryer Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was appropriately staffed to meet the needs of the people who use the service. Training is provided to provide staff with the skills they require.. Training must be reviewed to ensure all of the staff have attended the mandatory courses and staff receive common induction and foundation training. EVIDENCE: At the time of the Inspection the staff team comprised of three members of staff and an acting Manager. One member of staff is on duty during waking hours and member of staff sleeps in during the night. The Manager is only working in the home on a part time basis due to also working in another Life Opportunities Trust residential home. This issue will be addresses under standard 37. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 19 Staff have received mandatory training in Moving and Handling, First Aid, Fire Fighting, Food Hygiene, and Infection Control. However the record given did not confirm that all staff had completed these training courses. One member of staff had not received moving and handling, one food hygiene and one infection control. One member of staff has City in Guilds Care in the Community one has completed NVQ Level 2. Staff Induction Training records were not viewed on this occasion as personnel records were securely locked away. The Annual Quality Assurance Document confirmed that the common induction standards were not in place for new staff. On this inspection recruitment records were not viewed, one new member of staff had commenced employment as in July 2007. Standard 34 (recruitment) was met at the last inspection. The Annual Quality Assurance document stated that a recruitment policy was in place. Kingsway, 83a DS0000027068.V348822.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is without a Registered Manager and therefore does not have the individual leadership for the home. A system for quality assurance is in place, providing an ongoing process of practice review within the home. Systems for the management of health and safety throughout the home are generally good, however shortfalls could potentially place people who use the service staff and visitors at risk. EVIDENCE: A requirement of previous inspections had been for the Life Opportunities Trust to employ a Manager for Kingsway and for this person to be registered with CSCI. The time scales given for this requirement were 30th January 2006 and, Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 21 1st December 2006. The Inspector was informed that the post had been advertised but no appointment was made. LOT must continue to advertise and appoint to this post. Although the home is functioning well the staff team still need leadership and a permanent manager will be able to offer consistency. The home has a folder, which contains health and safety policies. The Annual Quality Assurance Audit confirmed that all the required health and safety policies were in place. Risks assessments were available for people who use the service and to cover general household risks. A fire risk assessment had been completed this was dated November 2006. This was a requirement of the last inspection. Risk assessment dated January 2006 should be reviewed. Fire Drills had taken place in September, October and November. According to the records viewed the last fire extinguisher check took place on 7th July 2006 and the last Gas safety check on 28th June 2005. Gas boilers and fire extinguishers must be checked annually. There is a Quality Assurance system in place; this was confirmed in the Annual Quality Assurance Audit. A Business plan for 2007 had been completed; this was a requirement of the previous inspection. Kingsway, 83a DS0000027068.V348822.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 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 3 x x 2 x Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA7 Regulation 15 (2) (b) Requirement The care plans must cover all elements of people’s care including any strategies for managing behaviour. The record of health care professional visits must be reviewed to ensure all the information is being recorded. The chart used for recording the administration of medication must be improved to provide a clear record. A review of mandatory training must take place to ensure that all staff have received this. The home must put forward a named individual to apply to be registered manager. Previous timescale 30/01/06 and 01/12/06 not met. An action plan to show how this is to be addressed must be submitted to CSCI. 6. 7. YA42 YA42 12 (1) 12 (1) Arrangements must be made to have the fire extinguishers checked annually. Arrangements must be made to DS0000027068.V348822.R01.S.doc Timescale for action 01/02/08 2. YA19 13 (1) (b) 01/02/08 3. YA20 13 (2) 01/02/08 4. 5. YA34 YA37 18 (1) (a) 8 (1) (a) 01/02/08 01/12/08 01/01/08 01/01/08 Page 24 Kingsway, 83a Version 5.2 have an annual service. 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 YA9 Good Practice Recommendations Risk assessments should be reviewed. Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Kingsway, 83a DS0000027068.V348822.R01.S.doc Version 5.2 Page 26 - 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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