Inspection on 09/08/05 for Madeley Road, 47

This inspection was carried out on 9th August 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Madeley Road, 47 21/06/07

Madeley Road, 47 23/01/06

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

CARE HOME ADULTS 18-65 47, Madeley Road Ealing London W5 2LS Lead Inspector Gavin Thomas Unannounced 9 August 2005 at 1.15pm 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. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 47, Madeley Road Address Ealing, London W5 2LS 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 8991 1333 020 8991 1387 info@cmg-corporate.com Care Management Group Ltd 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 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21/2/05 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 operates other care homes in the West London Office. 47 Madeley Road is a large detached house near the centre of Ealing Broadway. There are a wide range of shopping and transport facilities within walking distance of the home. The service users private accomodation 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. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 3.45 hours. The Inspector spoke with four services users, four staff, the Deputy Manager and the Registered Manager. One service user most recently admitted to the home said they had settled in well. The service user referred to staff as being “nice”. The other three service users spoken to said they were well. One service user was looking forward to a forthcoming holiday. The atmosphere in the home was very welcoming. All staff spoken to were co operative and pleasant in their approach. The Inspector also observed staff interacting pleasantly with service users and engaging some service users with household tasks. The Inspector spoke with the Registered Manager about her views on the provisions of the service. The Registered Manager’s views are included below. What the service does well: The home has a stable staff team. Resident spoken to indicated that they are happy in the home. Observations also indicated that good relationships are maintained between staff and service users. The staff team manage the daily activities for the majority of service users. Good opportunities are provided for service users to join in with activities both inside and outside the home. The Registered Manager was of the opinion that the home does well in encouraging and supporting service users to engage in meaningful activities. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 6 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. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 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 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 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 The Statement of Purpose and Service User Guide were well written and contained a wealth of information. Although the assessment processes were thorough and comprehensive, the home must ensure that service users are only admitted to the home whose assessed needs fall within the categories of registration. EVIDENCE: A Statement of Purpose and Service User Guide were in place. The Statement of Purpose had been revised and updated since the last inspection. The Registered Manager said that the contents of the Service User Guide had been explained to service users. There were no changes to the assessment process. The most recent admission to the home was in June 2005. The assessment conducted with this service user was detailed and comprehensive. It was noted however, that the service user’s assessed needs, were outside of the home’s category of registration. As a result, the home must make application to the CSCI to accommodate the service user in the home whose needs do not fall within the categories of registration. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 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 & 9 The quality of care plans and risk assessments in this home were good. However, proper training and support must be provided for staff regarding the Care Programme Approach. EVIDENCE: Care plans were in place for all service users. Updated care plans were in place for eight service users. Care plans for three service users were being typed at Care Management Group’s head office. Care plans examined were well written. Care plans are reviewed monthly with formal reviews taking place every six months. Where possible, service users are encouraged to sign their care plans and outcomes of their reviews. A specialist programme (Care Programme Approach) was in place for one service user. There was very little indication that staff were familiar with the Care Programme Approach for service users with a mental health diagnosis. Relevant training and professional support must be provided to ensure that staff are familiar with this process. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 10 The Registered Manager said that the implementation of the new care planning methodology has been postponed. This was due to the cancellation of relevant training for the staff team. Risk assessments examined were detailed and very specific to the needs of the individual service users. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 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, 13,14 & 17 Links with the community were good. The programme of activities was varied and maintained. The meals in this home were good, offering both choice and variety. EVIDENCE: Service users were involved in a range of community-based activities. These include shopping, meals out, social clubs, sports, trips to parks and places of interest. Service users continue to benefit from a mini bus, which is owned by Care Management Group. The home was still in the process of exploring more community-based activities for service users to choose from. Two service users were in paid employment, two service users were attending a day centre and one service user was doing a part time college course. The home is responsible for coordinating daytime activities for six service users. A structured activities programme was in place for all service users. Daily activities for individual service users are displayed in the dining room. Any changes to the daily activities programme are recorded in individual service users daily diaries. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 12 Leisure activities were incorporated in the daily activities programme. Where possible, service users are encouraged to pursue any hobbies. In door leisure activities include tabletop games, relaxation activities and music. Service users make good use of the garden for leisure activities when the weather is favourable. The menu examined indicated that service users are offered a wide range of balanced meals. Entries in the record of food served had much improved since the last inspection. Two service users spoken to said they enjoyed the food. The daily menu was displayed in picture form in the dining room. The Inspector observed one service user assisting with the preparation of the evening meal at the time of this inspection. The dining room was pleasantly furnished with sufficient facilities for all service users to eat together at any one time. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 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) 19 & 20 Overall, service users health needs are well managed. However, specialist training must be provided for staff to give them the underpinning knowledge in the event that they have to support one service user who has a mental health diagnosis. EVIDENCE: Service users health needs were set out in their care plans. One service user had moved on to a more appropriate placement since the last inspection for health reasons. The Registered Manager confirmed that all service users were registered with a GP. Annual health checks are carried out with all service users. Referrals for appointments with specialist health care professionals are made via the GP. All medical appointments are recorded. All service users have access to primary health care treatments. The home had done well in supporting one service user who was on a weight management programme. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 14 The health needs of one service user were discussed in great length with the Registered Manager to establish the home’s ability to manage any unforeseen incident. As a result of this discussion, it was clear that all staff must be provided with the necessary training to ensure that they are familiar with appropriate methods of intervention when managing any unexpected occurrences or changes in the service user’s health. The Registered Manager said that service users health needs were being well managed at the time of this inspection. A medication policy was in place. The Registered Manager said there were no changes to this policy. All medications are stored in a locked cabinet. The Registered Manager had submitted requests for training to Care Management Group for staff to attend refresher training in medication. The Pharmacist carries out routine pharmaceutical audits. Medication Administration Records examined were satisfactory. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 15 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 & 23 The complaints procedure for this service was satisfactory. Good practice systems were in place for maximising service users safety and protection. EVIDENCE: A complaints policy was in place. Two complaints procedures were in place. One complaints procedure was written for use by visitors and significant others. One complaints procedure was written for use by service users. The complaints procedure for service users was available in symbols and pictures. The service users complaints procedure was displayed in the dining room. In accordance with the record of complaints, this service last received a complaint in 2002. An adult protection policy and procedure was in place. A whistle blowing policy and a copy of the Department of Health – No Secrets guidance document were also available at the home. Staff last attended adult protection training in April 2004. The Registered Manager said there were no known concerns with regards to the safety or protection of service users. The home was still monitoring one service user who has the tendency to wander during the night. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 16 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 & 30 The overall standard of the environment is good. Communal rooms inspected were homely. Recent investment has improved the physical standards of the home, in particular the shower on the first floor. EVIDENCE: The ground floor of the home was clean and well presented. The Inspector did not carry out a tour of the first and second floors. The Registered Manager confirmed that repair works had been carried out in the shower room on the first floor. The ceiling in the office on the ground floor was stained as a result of water leakage from the bathroom on the first floor. The Registered Manager said that the maintenance person had carried out an initial assessment on the damaged ceiling. The Registered Manager also said that no one was at risk as a result of the water leakage and work will be carried out to repair the damaged ceiling in due course. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 17 A running maintenance programme was in place. A maintenance person has now been appointed to the West London services. The Registered Manager was of the opinion that this appointment has improved the timescales for completing all work in relation to the upkeep of the home. This home does not use any form of CCTV. The shed in the rear garden is used for general storage including tools and paints. The shed was not locked. The Inspector advised that the shed is kept locked at all time for safety reasons. This was done prior to the end of the inspection. Disused furniture items, which were stored under the fire escape in the rear garden, were judged to have an adverse effect on creating a “homely environment”. The Registered Manager did explain that the home would contact the local council to take these items away in due course. The furniture was rearranged prior to the end of the inspection. There were no offensive odours in the home at the time of this inspection. A policy on the control of infection was in place. Laundry facilities are situated on the ground floor. Service users have supervised access to the laundry for safety purposes. The home must still provide documentary evidence to confirm that the washing facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. This requirement remains outstanding from the previous two inspections. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 18 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) 35 & 36 Aspects of statutory training and the recording of formal supervisions must improve. There has been an improvement in the development of staff training and assessment and profiles. EVIDENCE: The organisation’s training department issues quarterly training programmes. Staff training requirements are selected and requested from the quarterly schedules. Training assessment and profiles were in place for all staff. It was identified on this inspection, that specific aspects of mental health and the planning of care for specific mental health needs must be provided as a matter of priority for all of the staff team. There was no evidence of TOPSS induction and foundation training and LDAF (Learning Disability Award Framework) training in the home. TOPSS induction and foundation training had not been completed for one member of staff who was appointed within the last six months. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 19 The Registered Manager confirmed that all staff are required to attend formal one to one supervisions every two months. Three senior staff had undertaken training to become supervisors. It was noted that no formal supervisions were recorded for one staff member for the year 2004. Only two formal supervisions had been recorded to date for the year 2005 for the same staff member. As a result of these findings, the recording of formal supervisions must improve. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 20 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 The Registered Manager has a good understanding of the areas in which the home could improve and develop. Process are being implemented whereby the home is beginning to review aspects of its performance through a programme of self – review and consultation with service users and significant others. EVIDENCE: The Manager was registered by the CSCI for this service in February 2005. The Registered Manager has been in her current post since February 2004. The Registered Manager said she has worked in various residential settings, which specialised for people with Learning Disabilities and Mental Health needs. The Registered Manager confirmed that she was working towards the Registered Manager’s Award. The Registered Manager is required to achieve this qualification by December 2005. The Registered Manager explained that she attends various training courses to keep abreast of current practice and for 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 21 her professional development. Recent training undertaken by the Registered Manager included budgeting, mentoring new staff, legislation and the law and disciplinary and grievance procedures. Quality assurance and monitoring systems were being implemented. An annual development plan was available in draft form. Surveys had been issued to service users, relatives and significant others. The Registered Manager said that the outcomes of surveys would be analysed and presented at the service users annual forum. These outcomes will also be included in the newsletter. The Inspector can confirm that copies of reports for Regulation 26 visits carried out at the home are supplied to the CSCI. 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 22 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 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 47, Madeley Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x x x G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 23 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 2 Regulation 12(1)(a) (b) Timescale for action The home must make application 9/9/05 to the CSCI to accommodate the service user in the home whose needs do not fall within the categories of registration. Relevant training and 31/10/05 professional support must be provided to ensure that staff are familiar with the Care Programme Approach for service users with mental health needs. Specilaist mental health training must be provided for the staff team. Documentray evidence must be obtained to confirm that the washing facilities and services comply with Water Supply (Water Fittings) Regulations 1999. (Timescale of 30/4/05 Not Met). All new staff must complete the TOPSS induction prcoess within six weeks of employment and the TOPSS foundation training within six months of employment. Evidence of this training must be retained at the home. Records of formal supervsions 31/10/05 30/9/05 Requirement 2. 6 18(1)(a) (c )(i) 3. 4. 19 30 18(1)(a) (c )(i) 13(4)(c ) 5. 35 18(1)(a) (c )(i) 31/10/05 6. 36 18(1)(a) 30/9/05 Page 24 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 must be kept for all staff. 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 Good Practice Recommendations 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor 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 47, Madeley Road G61-G10 s27749 Madeley Road v214207 090805 Stage 4.doc Version 1.40 Page 26 - 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. 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