Inspection on 08/03/06 for Lapworth Court, 17

This inspection was carried out on 8th March 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lapworth Court, 17 09/05/07

Lapworth Court, 17 28/06/06

Lapworth Court, 17 03/08/05

Lapworth Court, 17 13/01/05

Lapworth Court, 17 16/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 09/07/2008.

CARE HOME ADULTS 18-65 Lapworth Court, 17 Chichester Road London W2 6PL Lead Inspector Ffion Simmons & Wynne Price-Rees Unannounced Inspection 8 & 9th March 2006 11:00 th Lapworth Court, 17 DS0000010886.V285211.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 Lapworth Court, 17 DS0000010886.V285211.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. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lapworth Court, 17 Address Chichester Road London W2 6PL 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 7266 1694 020 7266 0631 Southside Partnership Miss Harpreet Ghatora Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd August 2005 Brief Description of the Service: 17 Lapworth Court is a registered care home providing care and accommodation for three women with a learning disability/mental illness. The care is provided by Southside Partnership and the home has an all female staff team. The home is situated on a small estate close to the shopping and transport facilities of Warwick Avenue, Bayswater and Paddington. A good standard of accommodation is provided and each person living in the home has her own bed sitting room. The Kitchen, bathrooms and toilets are shared. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. The inspectors spent time talking to one of the service users, staff and checking documentation. The communal areas and one of the service users’ bedrooms was seen during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: A total of eighteen requirements were set following this inspection. Four of the requirements are repeated from the last inspection, which relate to the need for communal areas of the home to be re-decorated. A requirement was also made to ensure that the smell of urine and faeces in one of the service users’ room is removed. Three requirements were made relating to medication practices, which is to ensure that medication administration records are improved and the use of correction fluid on MAR sheets to stop immediately. All liquid mediation must have the date of opening recorded and any old unused medication must be removed. Requirements were made relating to the home’s record keeping. The care planning system must be reviewed and daily notes must be improved. All incidents and accidents must be fully recorded and incidents affecting the welfare of service users must be reported to the CSCI. Missing person’s policy must also be followed at all times. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 6 Current staffing levels at weekends are not sufficient and must be reviewed to ensure that there are sufficient numbers of staff on duty to meet the current needs of the service users. Vacant positions must be filled with permanent staff. 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. Lapworth Court, 17 DS0000010886.V285211.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 Lapworth Court, 17 DS0000010886.V285211.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): 3 One of the service users living at the home does not want to live at the home any more and has expressed a wish to move out. Steps must be taken to ensure that these wishes are listened to and that the service user is supported to move on as per her requests. EVIDENCE: Currently one of the service users living at the home leaves the home unaccompanied and says that she does not wish to live at Lapworth Court any longer. Risk assessments have been completed and a missing person’s policy and procedure is in place. The Manager must ensure that this missing person’s policy is adhered to each time the service user leaves the home unaccompanied (please also see section on concerns, complaints and protection). A full placement review has been arranged with the input of the CPN/Care Manager to assess the home’s capacity for meeting the needs of this service user. The Manager must ensure that the CSCI is kept fully informed of the outcome of this meeting. Steps must also be taken to take note of the service user’s wishes and to explore the service users’ aspirations with regards to her future and to work with the service user to meet her requests for moving on. The inspector has suggested that it may be of benefit for the service user to have the input of an independent advocate worker to discuss thoughts, wishes and feelings. This referral has been made and this work is due to commence shortly. Lapworth Court, 17 DS0000010886.V285211.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): 6,9 Each service user has a plan of care outlining their needs, goals and activities outside the home. The current system of record keeping is difficult to follow and the review notes sometimes do not correspond to the goals set. EVIDENCE: Two residents’ files were case tracked and the Inspector found that there was a lot of out of date information in the files that needs to be archived. This made it difficult to access current information that is required to identify progress made towards the goals set within the care plans and how needs are being met. The care plan information was set out in three areas, care plan goals, person centred planning and activities carried on external to the home. This led to some confusion regarding reviewing of progress made. The care plans are numbered and these should correspond to the numbers within the reviews. One care plan numbered two referred to yoga exercises whilst in the review however, the information pertaining to number two was cleaning of a mattress. The heading of care plan three was regarding preparation for moving on, whilst no reference to this was made in the review under this care plan number. The care plans in place were underpinned by risk assessments internal to the home and activities outside. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 10 Individual diaries are used to track the activities attended on a daily basis, but they didn’t chart progress made towards the goals actually set outside the home. Set tasks to achieve goals, such as personal care and hygiene were tracked within the daily diaries. There were also individual weekly activity tasks on the office wall. The progress towards external goals tended to be given verbally by staff from day centres attended although there were external written reviews in place. The activities taking place in the home, that complimented those externally did not tend to be recorded that meant a lot of good work carried out by staff at the home was not documented. Lapworth Court, 17 DS0000010886.V285211.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 Service users have a full programme of activities and are supported to be part of the local community. EVIDENCE: Each service user has a programme of activities aiming to develop their social, communication and independent living skills. Service users have access to day services and some of sessions attended include Women’s group, drama, art and tennis. Each service user has an allocated time for tasks such as attending to their laundry, cleaning their rooms and helping with preparing for dinner. Service users have opportunities for socialising and be part of the local community. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 12 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): 20 Medication is securely stored but some gaps were noted in the medication administration records. Other shortfalls were also noted in the medication systems in the home. EVIDENCE: The medications in use in the home were securely stored in a locked metal cabinet. No controlled drugs are currently in use in the home. The medication administration records of all three service users were checked during the inspection. On the whole the records were well maintained but the inspector noted that there were some gaps in the medication records, where staff had not signed or used a code to explain if the medication had been administered. The inspector also noted that correction fluid had been used on one of the administration records. Both issues were discussed on the second day of the inspection with the Manager and on the second day of the inspection, some of the gaps had been accounted for. A bottle of liquid medication that had been dispensed in 2004 was still in the medication cabinet. There was no date of opening on this bottle. The Manager must ensure that the date of opening is clearly recorded and that any out of date or discontinued medication is removed as per their policy. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Policies and procedures are in place for the protection of vulnerable adults from abuse. Procedures are also in place for when service users leave the home and go missing. Care must be taken to follow this procedure and fully document the steps taken by staff when a service user goes missing from the home. All incidents must be fully documented. EVIDENCE: The home has a general written missing person procedure as well as ones that pertain to individuals and their specific needs. The daily diaries referred to instances of a person going missing although this tended to outline events rather than the course of action taken by staff. This made it difficult to ascertain if the procedure had been correctly followed. One entry stated that a staff member encountered a resident whilst on their way to work and the course of action they followed. The entry however did not record what staff on duty had done whilst the person was missing. Another entry stated that mum had phoned to say that a resident was with them. The procedure states that if the person was out and it was not known where they were going that stipulated contacts should be made. In both instances no record were found in the incident book. An adult protection policy and procedure is available for the protection of vulnerable adults from abuse. All staff receive training in the protection of vulnerable adults from abuse during their induction training. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 The home is comfortable and safe and service users’ bedrooms are spacious. The communal areas are still in need of redecorating, as this would improve the standard of the accommodation provided to service users. There was an offensive smell coming from one of the rooms. This needs to be removed, as it is very unpleasant for the service user living in the room. EVIDENCE: The home is situated on a small estate close to shopping and transport facilities of Warwick Avenue, Bayswater and Paddington. The home is suitable for the needs of the current service user group but would be unsuitable for service users with restricted mobility. Each service user living in the home have their own large bed sitting room. The bedroom of one of the service users was seen. The room is bright and spacious and contains the personal property of the service user including a TV, DVD and music system. There was a very strong smell of urine and faeces in this room and the window seat was soiled. It is a requirement that the Manager ensures that the smell of urine and faeces is removed and that a new window seat is provided. The kitchen, bathrooms and toilets are shared. It remains a requirement that the down stairs toilet, the main hallway, the kitchen and the office are redecorated. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34 There are a number of staff vacancies currently being covered by agency staff. This affects the continuity of care to service users. Staff rotas must be reviewed to ensure adequate staffing levels at the weekend, including the oneto-one support to enable service users to enjoy outside leisure activities and to promote their safety. EVIDENCE: The home has a number of vacancies that are covered by agency staff. The organisation has a bank of staff although it is difficult to access them as they are generally south London based where most of the organisation’s facilities are located and there are problems with travelling times. The use of agency has meant there is a difficulty regarding continuity of care although the home tries to use the same agency staff where possible. The Manager must ensure that vacant positions are filled with permanent staff. The staff rota reflected adequate numbers of staff on duty during the week as residents were attending activities at day centres. This became a problem on the weekends as the number of staff on duty meant it was very difficult if some residents wished to pursue activities outside the home and this has resulted in reliance on the goodwill of family and friends if they wished to go out. Records showed a pattern of higher incident levels on weekends. One of the strategies discussed for minimising the incidents and the associated risks, was to offer one-to-one support to a service user. This has not been Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 16 implemented and must be done as a matter of urgency to promote their safety. The organisation’s Human Resources department is responsible for the recruitment of new staff. The inspector saw documentation as evidence that confirmation is now sent to the Registered Manager that the necessary preemployment checks have been undertaken on new staff and that they are satisfactory. New staff are required to attend the organisation’s induction training programme. Training includes health and safety, equal opportunities and training in the protection of vulnerable adults. Each staff member has a training record outlining the courses undertaken and a system is in place for identifying when staff are due for training updates. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 17 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): 39, 42 Quality assurance systems are in place to review the quality of care offered to service users. Steps must be taken to ensure that all incidents are fully recorded and those falling under regulation 37 must be reported to the CSCI. EVIDENCE: A quality assurance system is in place and an annual report is produced. Monthly visit on behalf of the provider are undertaken and copy of the report forwarded to the Commission. The accident and incident records were checked as part of the inspection. Two incidents had been entered outlining that one of the service users had left the home unaccompanied on two separate occasions. The nature of this incident falls under Regulation 37 and must be reported to the CSCI. The inspectors also noted that incidents had been inputted into the diary notes but no incident forms had been completed. The Manager must ensure that all incidents must be fully recorded. Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 2 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 2 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 3 X X 2 X Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 14 Timescale for action The Manager must ensure that 15/04/06 the CSCI is kept fully informed of the outcome of the placement meeting due to be undertaken for one of the service users. Steps must be taken to register 15/04/06 the service user’s wishes and to work with the service user to meet their requests for moving on. The care planning system must 08/05/06 be reviewed to ensure that reviews undertaken reflect the numbered care plans. The daily diary notes must be 08/05/06 improved to ensure that they reflect on the goals set within the care plans and include more details about the work undertaken with service users both inside and outside of the home. The Manager must ensure that 03/04/06 the medication administration records are improved to ensure that they are correctly completed with no gaps. The use of correction fluid on 09/03/06 MAR sheets must stop immediately. DS0000010886.V285211.R01.S.doc Version 5.1 Page 20 Requirement 2. YA3 12 [2] 3 YA6 14 & 15 4 YA6 16 [2] (m) (n) 5 YA20 13 [2] 6 YA20 13 [2] Lapworth Court, 17 8 13 [2] 9 YA42YA 13 [4] & 13 [6] 16 [2] (k) 10 YA25 11 12 13 14 15 16 YA27 YA28 YA28 YA28 YA33 YA33 23 [2] (d) 23 [2] (d) 23 [2] (d) 23 [2] (d) 18 [1] (b) 18 [1] 17 YA33 18 [1] 18 YA42 37 The Manager must ensure that the date of opening is clearly recorded and that any out of date or discontinued medication is removed as per their policy. The Manager must ensure that the missing person’s procedure is followed and that all incidents are fully recorded. The Manager must ensure that the smell of urine and faeces is removed and that a new window seat is provided in a service user’s bedroom. The downstairs toilet is in need of re-decorating. Repeat requirement The kitchen is in need of redecorating. Repeat requirement The downstairs hallway is in need of re-decorating. Repeat requirement The staff office is in need of redecorating. Repeat requirement The Manager must ensure that vacant positions are filled with permanent staff. One-to-one support to one of the service user involved in recent incidents must be in place immediately. The Manager must ensure that the staffing rota is reviewed to ensure adequate staffing levels at weekends. The Manager must ensure that all incidents affecting the wellbeing of service users as outlined in regulation 37, are reported to the CSCI. 09/03/06 09/03/06 01/04/06 15/07/06 15/07/06 15/07/06 15/07/06 08/06/06 28/03/06 20/03/06 20/03/06 Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard YA6 YA30 Good Practice Recommendations The Manager should review the filing system of service users’ personal records and archive old records. The Manager should consider re-sitting the washing machines to ensure that soiled clothing are not carried through areas where food is stored and prepared. This is repeated Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 22 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 Lapworth Court, 17 DS0000010886.V285211.R01.S.doc Version 5.1 Page 23 - 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!