Inspection on 23/01/06 for Madeley Road, 47

This inspection was carried out on 23rd January 2006.

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

Other inspections for this house

Madeley Road, 47 21/06/07

Madeley Road, 47 09/08/05

Madeley Road, 47 21/02/05

Madeley Road, 47 26/07/04

Madeley Road, 47 16/03/04

Madeley Road, 47 28/08/03

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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 Madeley Road, 47 Ealing London W5 2LS Lead Inspector Mr Ged Durkin Unannounced Inspection 23rd January 2006 03:00 Madeley Road, 47 DS0000027749.V278009.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 Madeley Road, 47 DS0000027749.V278009.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. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Madeley Road, 47 Address Ealing London W5 2LS 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) 0208 991 1333 0208 991 1387 www.caremanagementgroup.com Care Management Group Limited Miss Diana Malunga Care Home 11 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0) of places Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: 47 Madeley Road is a registered establishment providing care to 11 service users with a learning disability who may also be over the age of sixty-five. The home is operated by Care Management Group, who also operate other care homes in the West London Office. 47 Madeley Road is a large detached house near the centre of Ealing Broadway. There are wide ranges of shopping and transport facilities within walking distance of the home. The service users private accommodation is situated on all three floors of the house. There is ample communal space available for service users including a well-maintained rear garden. The home was fully occupied at the time of this inspection. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 3 pm and 6:15 pm. The Inspector saw all the service users and spoke with a number of them. Some service users have a level of disability that means they are unable to communicate verbally but rely on other methods to communicate. The Inspector met with the Registered Manager and deputy manager and spoke to two other staff members. A number of records were examined and a tour of the downstairs premises was made. What the service does well: What has improved since the last inspection? 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. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 6 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 Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 7 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): 2 and 5 The home has a satisfactory assessment process in place and each service user has an appropriate written agreement/contract with the service. EVIDENCE: The home has a clear assessment process in place that sees prospective service users have a thorough assessment that includes a number of visits to the home, overnight stays and full involvement of any family. All the service users have a written contract/agreement that details rights, responsibilities and fees to be paid. There is still an outstanding issue regarding the home needing to make an application to vary its conditions of variation to accurately reflect the needs of all its service users. The Registered Manager said that she would follow this up with CMG. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 8 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 and 9. The quality of care plans was good. Risk assessments seen were detailed but incomplete. Service user consultation and participation in daily aspects of the home is given a high priority by staff. EVIDENCE: The Inspector saw a number of service user plans. All were well detailed and gave a good overall picture of the service user and his/her needs. All care plans are reviewed monthly. A daily record is kept by staff about each service user. The home operates a key worker system. The home consults service users through monthly meetings, key worker sessions, monthly reviews, family meetings and contact with senior representatives of CMG as part of their monitoring visits. The organisation also has an annual event that sees all the service users receiving a service from CMG get together in order to seek feedback and be informed of organisational developments. Service users also participate in daily activities in the home such as carrying out own laundry duties, communal cleaning and assisting staff in meal preparation or helping to clear away afterwards. Some of the risk assessments examined, although detailed did not have a date as to when they were reviewed. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 9 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): 15, 16 and 17. Service users have appropriate family and personal relationships, have their rights and responsibilities recognised in their daily lives and have a healthy and varied diet. EVIDENCE: The Registered Manager informed the Inspector that some service users have more family input than others and some have external friendships outside of the home. Staff facilitate, when appropriate, service users to develop external interests that see service users coming into contact with a wider circle of people, i.e. going to the local pub. Service user’s rights are observed in a number of ways that include individual receipt of their post and making and receiving phone calls in private. All the service users undertake a number of domestic duties around the home in recognition of their responsibility to each other in a communal setting. The home has a four week rotating menu. The main meal of the day is in the evening. The Inspector saw service users preparing to sit down for this main meal, which consisted of toad in the hole with mixed vegetables and salad. One service user expressed her anticipation for this meal, which looked appetising and well presented. Staff under take the majority of cooking in the home with some service user assistance. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 10 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 home ensure that all the service user’s health and social care needs are met in a satisfactory manner. There are appropriate medication systems in place in the home. EVIDENCE: The Registered Manager informed the Inspector that some service users are in more need of personal support than others. Some service users need verbal prompting while others need more direct support. The Registered Manager informed the Inspector that what ever the level of support needed by service users staff then it was given on as thorough basis as was possible. All the service users are registered with local GPs but no individual service users have any specific health care conditions that need particular medical interventions. Staff are helped in giving any emotional support to service users by monthly visits from a psychologists. No service users self medicate. All medication is kept securely in a purpose built cupboard. The home uses a monitored dosage system and staff receive appropriate training in medication matters. The Inspector examined a number of medication administration sheets and found all were in order. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 11 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 home has a number of ways that demonstrate service users views are listened to and acted upon. The complaints procedure is satisfactory and systems for ensuring service user protection were in place. EVIDENCE: All service users have monthly in house reviews, key worker sessions, service user house meetings and a CMG annual service user forum that are opportunities for service users to make their views known and acted upon. Yearly questionnaires are sent out to families to seek their feedback as to how they view the quality of the service their relatives receive. All staff attended adult protection training in April 2005. The complaints procedure for the home was on display in the entrance to the house. The home has not received any complaints since the last inspection. One staff member interviewed did not understand the term “Whistle blowing” but was able to tell the Inspector what she would do in the event of observing any form of abuse. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 12 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, 29 and 30. The home has some maintenance issues but otherwise would appear to be a comfortable, safe, clean environment able to meet the needs of the service users who live there. EVIDENCE: The office ceiling is the subject of a bad leak, which has also affected one of the walls, which has meant that shelves can no longer be attached, that usually contain documentation. The net effect of this is that in a relatively small office it is cluttered because of this lack of shelving necessitating documentation being piled on top of cupboards or on the floor. The Registered Manager informed the Inspector that remedial work for the leak in the ceiling was on going. The downstairs toilet and laundry area are in need of refurbishment because of wear and tear. Although the home has new dining furniture, the furniture in the main communal lounge was beginning to look worn and will need replacing at some point in the future. There were still remnants of Christmas decorations in the main lounge, which the Registered Manager had attended to during the inspection. The home does not use any specialist equipment for any of its service users. The home is in the process of appointing a domestic for the home so care staff and service users were responsible for the cleanliness of the home, which seemed to be to a satisfactory standard. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 13 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 and 34 Service users benefit from an effective staff team that have been subject to robust recruitment procedures. EVIDENCE: The staff team has three staff in the morning and three in the afternoon. The Registered Manager works across the day and gives support as required. At night there is one waking night and one sleeping in staff. Extra staff are brought in to support service users when undertaking activities. The home operates a thorough recruitment process that sees the company human resource department co-ordinate advertising and short listing while senior staff at the home conduct interviews and make final selections. The Inspector examined two staff files and found all the necessary documentation was in order. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 14 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): 38, 39 and 42. The service users benefit from an open and inclusive management approach with their views underpinning service development. The home has good health and safety systems in place. EVIDENCE: The Registered Manager offered the view that she had an open style of management that encouraged contact with service users, families and staff. This was evidenced by the number of times differing service users came into the office for a variety of reasons. All were comfortable and at ease in her presence. Monthly reviews, key worker sessions, annual placement reviews, annual questionnaires sent to families and CMG service users forums are all ways in which service user views are elicited to underpin service development. The Inspector examined a number of health and safety documents and found all were in order. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 15 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 2 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 3 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x 3 3 x x 3 x Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 16 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 YA2 Regulation 12(1)(a) (b) Timescale for action The home must make application 20/02/06 to the CSCI to accommodate the service user in the home whose needs do not fall within the categories of registration. Time scale of 09/09/05 not met. Risk assessments for service 27/02/06 users must show the date when reviewed. The leak in the office ceiling and 06/03/06 remedial damage must be repaired. An action plan outlining dates for 03/04/06 renovation of the downstairs toilet and laundry room must be submitted to CSCI. Requirement 2. 3. 4. YA6 YA24 YA24 13 (4) (c) 23 (2) (b) 23 (2) (d) 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 YA23 Good Practice Recommendations The topic of adult protection should be a standing item at team meetings. Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 17 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. Extracts may not be used or reproduced without the express permission of CSCI Madeley Road, 47 DS0000027749.V278009.R01.S.doc Version 5.1 Page 18 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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