Inspection on 01/12/05 for Laverstoke Gardens

This inspection was carried out on 1st December 2005.

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

Other inspections for this house

Laverstoke Gardens 25/07/06

Laverstoke Gardens 07/07/05

Laverstoke Gardens 28/12/04

Laverstoke Gardens 20/05/04

Laverstoke Gardens 08/01/04

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 Laverstoke Gardens 49 Laverstoke Gardens London SW15 4JB Lead Inspector Jon Fry Unannounced Inspection 10:00 1 December 2005 st Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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 Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Laverstoke Gardens Address 49 Laverstoke Gardens London SW15 4JB 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 8246 6824 020 8788 9382 The Frances Taylor Foundation Ms Barbara Pauline Curley Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: 49 Laverstoke Gardens is a care home for seven adults with a learning disability. The service is located in a quiet residential road in Roehampton close to local shops and transport links. The home is a two-storey purpose built building. All the bedrooms are single, one of which is on the ground floor and wheelchair accessible. The home is run by The Frances Taylor Foundation. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by a regulation inspector on the 1 December 2005. The inspection took place over two hours. The inspector spoke with three residents and two members of staff. A number of records were examined, as well as a tour of the communal areas of the home. It is recommended that the last report from July 2005 be read along with this document to gain a fuller picture of how the home is meeting National Minimum Standards. What the service does well: What has improved since the last inspection? What they could do better: Medication must be stored securely at all times and any expired items disposed of promptly. Risk assessments for individual residents must be kept under review so that they are up to date. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 6 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. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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 Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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): 4. Prospective residents are able to visit and ‘test drive’ the home before admission. EVIDENCE: A satisfactory assessment and admission procedure clearly outlines the process for all prospective residents. The procedure includes opportunities for the new resident to make introductory visits to the home. There is a trial period of three months followed by a review meeting. There have been no new admissions to the home since the previous inspection. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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 and 9. The care plans for residents are kept to a high standard and make sure that individual needs of residents are addressed on an on-going basis. Staff carry out individual risk assessments to promote the safety and independence of residents. An improved review process for these assessments must be developed. EVIDENCE: The care plan for one resident was looked at during this inspection. This document was well organised and clearly showed a ‘live’ process of support planning for the individual resident. The plan covers areas of need such as mobility, communication and activities. A Person Centred Planning (PCP) book is also completed with each resident. The book seen at this inspection had been completed by the resident. Good information such as individual likes and dislikes, preferences for food and their ‘ideal day’ were noted. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 10 A six monthly review schedule for residents was displayed at the time of inspection. Risk assessments were looked at for two residents and these addressed potential areas of risk such as mobility and the use of stairs. The process for the review of risk assessments needs to be improved and these must be clearly documented. A number of assessments seen were past their review date at the time of this inspection visit. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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): 14, 15 and 17. Residents are supported to take part in activities and to be part of the local community as required. Residents receive appropriate support to maintain contact with their family and friends. Individual dietary needs are well catered for. EVIDENCE: Residents take part in a range of different activities. One resident said that they went to college to do sculpture, basic skills and cooking. Other residents also go to local colleges to do activities such as art, sewing and singing. One resident stated that they were in supported employment at a café. A weekly activities planner is displayed for residents. This is completed each week and the current plan included massage, relaxation, card games and a video evening. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 12 The lounge area has television, video, music and karaoke equipment for residents use. Artwork by residents is displayed in the home along with photographs of recent holidays. Two residents said that they had contact with their family. Staff had recently taken one resident to see their previous residential home. Pictures of the family and friends of one resident were a part of their Person Centred Planning book. Two residents were writing their Christmas cards at the time of inspection. Menus are displayed in the kitchen. Residents were positive regarding the food provided and comments included “fine” and ”I help choose the menu”. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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): 20. Good medication systems are in place for the protection of clients. Two shortfalls were however observed at the time of this inspection. EVIDENCE: An organisational procedure for medication is available for reference by staff. Medication administration records are well maintained at the home. A good system is in place to make sure that medication is correctly given as prescribed. The main supply of medication is securely stored within an office at the home. One instance was however seen where an additional medication cupboard containing prescribed creams in the ground floor bathroom had been left unlocked. One prescribed cream that was not in everyday use was past its use by date as marked on the packaging. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 14 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 and 23. An appropriate complaints procedure is in place at the home. Satisfactory procedures are additionally in place for the protection of vulnerable adults. EVIDENCE: An accessible complaints procedure is in place. No complaints have been received by the home or by the CSCI since the previous inspection in July 2005. Clear procedures regarding abuse are available to make sure that staff have an understanding of their role and responsibility in reporting any concerns to the appropriate persons. A resident raised an issue regarding a recent incident outside of the home during this inspection visit. The inspector was satisfied that this had been dealt with appropriately by the home. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 15 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 and 30. The standard of accommodation is good providing residents with a comfortable and homely place to live. The home is kept clean and hygienic. EVIDENCE: The home provides comfortable and homely accommodation to residents that is maintained to a good standard. Available communal space includes a lounge, kitchen and dining area and a garden with accessible patio. No maintenance issues were seen during this inspection. The recommendation for the organisation to consider the addition of a conservatory area has again been included within this report. Staff on duty did not know if this plan had been agreed by the organisation. No maintenance issues were seen during this inspection and all areas of the home were kept clean and tidy. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 16 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): 33, 35 and 36. An effective staff team meets the individual needs of residents. Satisfactory opportunities are provided for staff to take part in training. Residents’ benefit from well supported and supervised staff. EVIDENCE: Three members of care staff are on duty during busy periods with a minimum of two staff members are on duty at the home at any one time. Comments from residents included “the staff are great”, “they are polite and kind” and “ok”’. Two staff on duty reported that a new training schedule was going to start in January 2006 and this included refreshers for basic training such as first aid and food hygiene. Care staff continue to be well supported and supervised by a temporary manager. A supervision schedule was displayed and two staff said that they were continuing to have regular supervision sessions. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 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): 37 and 39. Residents’ benefit from a well run home. The views of residents, their representatives and other stakeholders are obtained as part of the quality assurance system in place at the home. EVIDENCE: The current manager was on extended leave and the ex-manager of the home was providing cover at the time of this inspection. Staff members reported that this arrangement was satisfactory with one individual saying that “things were going well” at the home. Monthly resident meetings take place and include discussion about areas such as holidays and activities. It is again recommended that the minutes of these meetings clearly specify actions required and are formally discussed within the monthly staff meetings. The documents seen at this inspection did not confirm that this was being done as recommended following the July 2005 inspection. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 18 An organisational quality assurance system is in place and this is based on the applicable National Minimum Standards. A questionnaire compiled by the home for residents, relatives and other stakeholders had been sent out since the last inspection. The responses seen were very positive and included comments such as “staff are very caring and can’t do enough for the residents”. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Laverstoke Gardens Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000010205.V269439.R01.S.doc Version 5.0 Page 20 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 YA9 Regulation 12 (1) 13 (4) Requirement The Registered Persons must ensure that the risk assessments in place for individual residents are subject to a documented review process and are updated as necessary. The Registered Persons must ensure that: all items of medication are securely stored at all times, any items of medication past their expiry date are disposed of promptly. Timescale for action 01/02/06 2. YA20 13 (2) 01/12/05 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 YA24 Good Practice Recommendations It is recommended that the provision of a conservatory to the rear of the property be seriously considered by the DS0000010205.V269439.R01.S.doc Version 5.0 Page 21 Laverstoke Gardens 2. YA39 organisation. It is recommended that the minutes of resident meetings include actions required and by whom. Matters arising should be discussed within the staff meetings to ensure follow through. Laverstoke Gardens DS0000010205.V269439.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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