Inspection on 21/12/05 for Little Road, 2

This inspection was carried out on 21st 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Little Road, 2 14/08/07

Little Road, 2 05/10/06

Little Road, 2 07/09/05

Little Road, 2 20/01/05

Little Road, 2 23/09/04

Little Road, 2 02/09/03

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Little Road, 2 Hayes Middlesex UB3 3BT Lead Inspector Robert Bond Unannounced Inspection 21st December 2005 10:00 Little Road, 2 DS0000027065.V268895.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 Little Road, 2 DS0000027065.V268895.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. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Little Road, 2 Address Hayes Middlesex UB3 3BT 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 8848 9126 Life Opportunities Trust Mrs Marva Denise Frederick Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 Brief Description of the Service: 2 Little Road is a residential home for six service users with learning disabilities. The home was registered in 1995. Shepherds Bush Housing Association owns the home and the care provider is Life Opportunities Trust. The home is a six bed roomed, semi-detached house, located in Hayes and is within walking distance to the town centre, the main line station and public transport facilities. The home has six single bedrooms. Two are on the ground floor. There are no facilities for service users who are disabled. The ground floor has a lounge/dining area, which is comfortably furnished, for the service users. The kitchen, one small toilet, a shower room with a toilet and the utility/storage room are also on the ground floor. There is a bathroom with a toilet, and the office, on the first floor. The service users bedrooms are at least 14.1 square metres and are fitted with TV points and emergency call systems. There is a small rear garden, which is mostly lawn, with a patio area. Limited parking is available in the street. The staffing structure consists of a Registered Manager, a deputy, a senior, two full time and two part time day residential workers and one full time waking night staff. The staff provide support with personal care, practical tasks and leisure activities. There are two staff on duty at times when the majority of the service users are in the home, which includes the Registered Manager. One staff is on a waking night duty, with an on call system in case of emergencies. Little Road, 2 DS0000027065.V268895.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 the second of the year and the emphasis of both inspections has been on assessing the outcomes of the key standards that form part of the Government’s National Minimum Standards (NMS). The Inspector met the deputy manager, one of the support workers and four of the service users. He toured the building and inspected various records and policies and examined in detail (case-tracked) the care file of one service user. The home is fully occupied. The Deputy Manager reported that there are two staff vacancies, namely the senior support worker and one regular support worker. She hoped that interviews would be held during January 2006. He assessed the outcomes of 22 the National Minimum Standards, and found that 18 were fully met, and 4 were only partly met. The Inspector made 5 requirements, of which 2 are restated from the previous inspection having not been achieved within the timescale set. What the service does well: What has improved since the last inspection? Most of the staff have now had training in Adult Protection provided by the London Borough of Hillingdon. A larger garden shed has been purchased that will be used for the storage of wheelchairs and walking frames. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 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. Little Road, 2 DS0000027065.V268895.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 Little Road, 2 DS0000027065.V268895.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): No new service users had moved into the home since the last inspection so these outcomes were not re-assessed. EVIDENCE: Little Road, 2 DS0000027065.V268895.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, 7, 8, 9 and 10 All the outcomes are fully met. EVIDENCE: The Inspector case-tracked (examined in detail) a care file for one of the service users, chosen at random. The file was well-maintained, detailed, contained the necessary information, and a review of the plan and care provided had taken place during the previous 12 months. Appropriate consultation appeared to have taken place. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 10 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): 11, 12, 13 and 14 The outcomes for all the above are fully met. EVIDENCE: The Care Plan examined contained details of leisure interests, activities undertaken and day centre attendance. On the day of the Inspection, two service users were attending a day centre. The other four service users were clearly enjoying watching a television together with a member of staff. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 11 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): 18, 19 and 20 The outcomes are fully met. EVIDENCE: The Inspector spoke to all the service users present and ascertained as far as he was able that all were satisfied with their care. The care plan examined covered aspects such as provision of personal care, and health matters. The Inspector examined the storage of medication and the records of its administration. Only one error of recording was noted. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 12 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 The outcome for NMS 22 is fully met. The outcome for NMS 23 is partly met for the reasons stated below. EVIDENCE: NMS22: The deputy manager reported that the home had not received any formal complaints since the last inspection. NMS23: The deputy manager reported that all the staff group except one had undertaken training at the home on adult protection, provided by The London Borough of Hillingdon’s Adult Protection Department staff. That one member of staff must also receive the training. Requirement 1. The deputy manager was not able to produce for the Inspector a copy of Hillingdon’s updated policy and procedure booklet which is called Safeguarding People. Requirement 2. The Inspector examined the home’s policy document on adult protection. The document referred to the NCSC (now CSCI) but made no reference to each Council now having an Adult Protection Department that will convene strategy meetings to consider how the investigation of any allegations of abuse will be investigated. Requirement 3. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 13 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 to 30 inclusive. NMS 24 and 30 are only partly met for the reasons stated below. The remainder are fully met. EVIDENCE: The Inspector toured the home with the deputy manager and saw all parts including two service users’ bedrooms. The outcomes of the NMS were met, except: 1. that cleaning chemicals were found to be kept in a kitchen cupboard that had not been locked up. The deputy manager locked the cupboard straight away. Requirement 4. 2. Spilled food has soiled the carpet in the hallway between the kitchen and living room. Requirement 5. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 14 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): These outcomes and standards were not assessed at this inspection. Three of this group of standards were assessed at the previous inspection and their associated outcomes were assessed as being fully met. EVIDENCE: Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 15 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): 42. The outcome was not fully met for the reason stated below. EVIDENCE: The Inspector checked the records of fridge and freezer temperatures and those of hot water temperatures. All were in order. The outcome is not fully met because the cleaning chemicals kept in the kitchen were in a cupboard that had not been locked shut. Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 16 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 x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Little Road, 2 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x DS0000027065.V268895.R01.S.doc Version 5.0 Page 17 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 YA23 Regulation 13 (6) Timescale for action All staff must have updated adult 01/04/06 protection training. THIS IS A SLIGHTLY AMENDED RESTATEMENT OF THE PREVIOUS REQUIREMENT. The timescale of 31/10/05 had not been met for all staff. The home must obtain and have 01/02/06 available to all staff the current London Borough of Hillingdons adult protection policy. THIS IS A SLIGHTLY AMENDED RESTATEMENT FROM THE PREVIOUS INSPECTION. The timescale of 31/10/05 had not been met. The home’s written policy and 01/03/06 procedure on Adult Protection must make reference to the CSCI and the Adult Protection Department that each Local Authority now operates. Service users must be protected 01/01/06 from unnecessary risk by keeping COSSH materials securely locked away at all times The part of the hall carpet that is 01/03/06 soiled must be cleaned or replaced. Requirement 2. YA23 13 (6) 3 YA23 13 (6) 4 YA42YA24 13 (4) (a) 5 YA30 23 (2) (d) Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Little Road, 2 DS0000027065.V268895.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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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