Inspection on 07/07/05 for Laverstoke Gardens

This inspection was carried out on 7th July 2005.

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 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 01/12/05

Laverstoke Gardens 28/12/04

Laverstoke Gardens 20/05/04

Laverstoke Gardens 08/01/04

Similar services:

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Edenvale

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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 7th July 2005 10:30 am 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 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 Stationary 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 G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Laverstoke Gardens Address 49 Laverstoke Gardens London SW15 4JB Telephone number Fax number Email 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 CRH Care Home 7 Category(ies) of LD Learning Disability (7) registration, with number of places Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th October 2004 Brief Description of the Service: 49 Laverstoke Gardens is a care home providing personal care and accommodation for seven adults with learning disabilities. The Frances Taylor Foundation owns the home. The house is in keeping with neighbouring properties and is not identifiable as a care home from the outside of the property. The home is located in Roehampton, close to shops, library, leisure centre, pubs, the post office, Richmond Park and other amenities. The home is a two-storey purpose built building. All the homes bedrooms are single, one of which is on the ground floor and wheelchair accessible. There is no passenger lift or wheelchair access to the other bedrooms. The home has a rear garden, which has recently been landscaped and provides a pleasant outdoor area for service users. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector on the 7th July 2005. The inspector spent approximately five hours in total at the home. The inspection included the examination of records, a partial tour of the premises and individual conversation with three residents, the acting manager and two members of staff. What the service does well: What has improved since the last inspection? What they could do better: The report highlights areas for development such as ensuring the quality assurance system is fully implemented and is based on consultation with residents and / or their representatives. It is recommended that the monthly unannounced visits made by representatives of the organisation focuses on the views of residents and staff rather than assessing National Minimum Standards. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 6 The general training provision by the organisation is very good but the home must ensure that all individual members of staff have received up to date training in areas such as First Aid and Food Hygiene. This was not fully evidenced at the time of inspection. The inspector however acknowledged that changes were being made within the organisation as to how this training was to be provided in the future and this had led to delays in booking courses. 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 G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 1, 2 and 5. Prospective residents and / or their representatives are provided with good information regarding the home. The aspirations and needs of prospective residents are assessed by the home prior to admission. A copy of the applicable contract for the home is provided to all residents. EVIDENCE: A Statement of Purpose and Service Users (residents) Guide are in place as required by the applicable National Minimum Standards. A copy of the Guide for the home was observed to be kept on file for each resident and this document is available in Makaton format. A comprehensive assessment and admission procedure is in place and this clearly outlines the process for all prospective residents. This is important as it ensures that the home is able to meet their individual needs and personal goals. There have been no new admissions to the home since the previous inspection. The care files for two residents were seen to include copies of the contracts in place. These lay out the rights and obligations of the home and the individual resident including the fees payable, room to be occupied and full details of any ‘extra’s not included within the weekly fee. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 and 9. The care plans in place for residents are maintained to a high standard and ensure that individual needs of residents are addressed on an on-going basis. Risk assessment documentation is in place as part of the process to allow residents to be as independent as possible. EVIDENCE: The care documentation examined for two residents was seen to be up to date and subject to an ongoing process of evaluation and review. An up to date care plan was seen to be in place covering areas of need such as mobility, communication and activities. Person Centred Planning (PCP) profiles were additionally seen to be have been completed and these included good information such as individual likes / dislikes and preferences for food and their ‘ideal day’. A six monthly review schedule was displayed at the time of inspection. Risk assessments were seen to be in place for both residents whose documentation was examined. These were observed to address potential areas of risk for individuals such as travel and medication. All assessments examined had been reviewed as appropriate but it is recommended that the Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 10 method of recording these reviews be amended to clearly evidence the ongoing process. Three residents were spoken to individually and each person reported that they were satisfied with the overall service provided. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 12, 13 and 17. Residents are supported to take part in appropriate activities and to be part of the local community. The service promotes independence and individual choice for the residents accommodated. Individual dietary needs are well catered for. EVIDENCE: Residents participate in a variety of day activities. One resident reported that they attended college and were due to attend their ‘women’s group’ that afternoon. Other residents attend local colleges or Day Centres to engage in activities such as art, sewing, keep fit and singing. One resident stated that they had started supported employment at a café recently. The lounge area was seen to be equipped with television, video, music and karaoke equipment. Two residents reported that they were off on holiday to Ireland within the next week. A member of staff additionally reported that they were also planning to go with a resident for a day trip to Brighton. An activities planner was observed to be on display at the time of inspection – this included scheduled trips to the pub for individuals as well as in-house activities such as massage Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 12 and aromatherapy. One member of staff reported that residents enjoyed trips to nearby Richmond Park and regularly accessed local High Street shops via public transport. One resident was observed to return from a trip to the bank with a member of staff on the day of inspection. The current menu was seen to be displayed in the kitchen and included meals such as salmon, roast gammon, and chilli con carne. The residents spoken to were positive regarding the food provided – comments included ‘ we had salmon yesterday which was lovely’ and ‘we can ask for something different if we want to’. The manager reported that residents were supported to choose the menus on a weekly basis by staff. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20. Residents receive appropriate levels of support to ensure their physical health needs are met. Full and accurate records are maintained to ensure the safe administration of medication to residents. EVIDENCE: Personal care needs were seen to be well documented within individual care plan documentation examined for two residents. Care documentation examined showed that appropriate support was provided to ensure that individual physical health needs were met. Records of contact fully evidenced that individuals access GP, dental and optician services within the local community. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 22. An appropriate and accessible complaints procedure is in place at the home. This serves to ensure that resident’s views are listened to and acted upon. EVIDENCE: A complaints procedure is in place and this was observed to be on display at the time of inspection. An accessible version in Makaton is available to residents as appropriate. No complaints have been received by the home or by the CSCI since the previous inspection. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 28, 29 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 well maintained accommodation to residents. Available communal space includes a dedicated lounge, kitchen / dining room and a patio area in the garden to the rear. Each resident benefits from single bedroom accommodation and the manager reported that three bedrooms were due to be painted as part of the ongoing maintenance programme. The inspector was informed that the home was investigating alternative flooring for one residents bedroom following a recent fall. It is recommended that this be actioned as soon as possible. The inspector identified that there had been no progression regarding the conversion of the garage space to an activities room. One member of staff spoke regarding the possibility of a conservatory area being provided instead Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 16 of the garage conversion. The manager confirmed that this had been discussed as a possible alternative project – a recommendation has been included within this report for this to be considered further. Additional accessible communal space such as a conservatory would further benefit residents and could be utilised for a number of purposes. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 35. Appropriate numbers of staff are on duty at all times for the health and welfare of the residents accommodated. A programme of training is in place but the provision requires further review to ensure all staff have received up to date training in areas such as First Aid and Food Hygiene. This is essential to fully ensure the health and welfare of residents accommodated. 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. Residents spoken to reported that staff numbers were satisfactory and comments included ‘the staff are very nice’ and ‘good’. One staff member spoken to stated that they felt that the service was ‘very impressive’ and another stated that the staff team were ‘very good’. An organisational training programme is in place and two staff members spoken to reported positively on the availability of training at the home. Records of training examined were seen to include courses regarding moving and handling, medication, care planning and abuse awareness. The home must ensure that all care staff are in receipt of up to date basic training such as First Aid and Food Hygiene. The provision of this training was not fully Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 18 evidenced at the time of inspection although the manager reported that this was due to be addressed shortly. This is essential to fully ensure the health and welfare of residents accommodated. The competency of staff members is however further ensured through access to NVQ training. The manager stated that two members of staff have the NVQ Level Three qualification with a further two currently studying to attain this award. One member of staff is additionally finishing their course of study for the NVQ Level Two qualification. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42. Continuity of management and leadership is provided by the manager who was previously in post as deputy home manager. Residents therefore continue to benefit from a well run home. Good systems are in place to ensure the health and safety of residents. An organisational quality assurance system is in place at the home. This must be further developed to ensure that the views of residents, their representatives and other stakeholders are obtained formally. EVIDENCE: The current manager was previously the deputy manager of the home and has applied to become registered with the CSCI. This provides continuity for both staff and residents at the home and feedback received regarding the manager was positive on the day of inspection. This included comments from staff such as ‘supportive’ and ‘accessible’. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 20 Resident meetings take place on a monthly basis and this allows for discussion and forward planning regarding areas such as holidays and activities. It is recommended that the minutes of these meetings clearly specify actions required and are formally discussed within the staff meetings that also take place on a monthly basis. An organisational quality assurance system is in place and this is based on the applicable National Minimum Standards. A questionnaire has been devised by the home for residents and relatives / representatives and the acting manager reported that this was due to be sent out shortly. It is essential that this consultation takes place and that the information collected is utilised to inform the annual development plan for the service. Monthly unannounced visits take place by a representative of the organisation. The written reports now include an assessment of a number of National Minimum Standards. This was discussed with the acting manager and the inspector was of the opinion that these assessment duties may detract from individual discussion with residents and staff on duty. The organisation must also ensure that the report includes all information as required by the Care Homes Regulations 2001. Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 x x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Laverstoke Gardens Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x 3 x G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18 (1) (c) 13 (4) 2. YA39 26 (4) Requirement The Registered Persons must ensure that all care staff are in receipt of up to date training with regard to Food Hygiene and First Aid. The Registered Persons must ensure that the reports of the monthly unannounced visits fully address all areas as specified within this Regulation. Timescale for action 01.10.05 01.09.05 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. 2. 3. 4. Refer to Standard YA9 YA25 YA28 YA39 Good Practice Recommendations It is recommended that the method for recording the reviews of risk assessment documentation is amended to clearly evidence an ongoing process. It is recommended that the flooring in one residents bedroom is changed as soon as possible. It is recommended that the provision of a conservatory to the rear of the property be seriously considered by the organisation. It is recommended that questionnaires be sent out annually to residents, their representatives and other stakeholders. Responses should then be utilised to inform G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 23 Laverstoke Gardens 5. YA39 the annual development plan for the service. 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 G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon 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. Extracts may not be used or reproduced without the express permission of CSCI Laverstoke Gardens G54-G04 S10205 Laverstoke Gardens V238703 110705 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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