Inspection on 28/04/05 for Marriott Road 18

This inspection was carried out on 28th April 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 but made no statutory requirements on the home.

Other inspections for this house

Marriott Road 18 12/10/06

Marriott Road 18 20/09/05

Marriott Road 18 05/10/04

Marriott Road 18 05/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 18 MARRIOTT ROAD Barnet Hertfordshire EN5 4NJ Lead Inspector Tom McKervey Announced 28 April 2005 @ 09.30am 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. 18 MARRIOTT ROAD Version 1.10 Page 3 SERVICE INFORMATION Name of service 18 Marriott Road Address 18 Marriott Road, Barnet, Hertfordshire EN5 4NJ 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 8449 9493 Alison Forbes for Hoffman Foundation for Autism Vacant Post Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places 18 MARRIOTT ROAD Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5/10/04 Brief Description of the Service: Marriot Road is a care home registered to provide care and support for six younger adults who have a learning disability, and who also have autism. The Hoffman de Visme Foundation, which is a registered charity, manages this home, and other similar homes in the U.K. The home opened in 1989. The property comprises a three-storey townhouse, situated in a pleasant residential area of High Barnet. It is close to shops and leisure amenities and there are good public transport links. There are three bedrooms on the first and second floor. The kitchen/diner is located on the ground floor, and there is an attractive garden to the rear of the property. 18 MARRIOTT ROAD Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted over a period of seven hours. The purpose of the inspection was to determine what progress had been made since the last time the service was inspected, and to identify any shortfalls. The acting manager was present throughout the inspection and fully cooperated with the process. At the time of the inspection, there were six service users living at the home and there were no vacancies. A tour of the premises was carried out, including service users’ communal areas and bedrooms. Care records were examined and staff were interviewed. At the start of the inspection, the inspector was able to meet five service users who were preparing to leave for their day centres, and again on their return. One other service user was present for various periods, but also went out for planned activities outside the home. The inspector spoke to staff independently, and found that they were very committed and caring, knowledgeable about the service users, and that their morale was very good. The inspector formed the view that the service users were well cared for and enjoyed a good standard of life in the home. Although there were no visitors on the day of the inspection, three relatives and three professional staff sent comments to the Commission for Social Care Inspection, which were very complimentary about the service. What the service does well: There is a core group of staff that has worked at the home for a long time and are very knowledgeable and caring about the service users. The acting manager gives clear leadership and staff are well supervised. There is a strong emphasis on integrating with the local and wider community and relatives are welcome to be very involved in the running of the home through their peer group. 18 MARRIOTT ROAD Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 18 MARRIOTT ROAD Version 1.10 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 18 MARRIOTT ROAD Version 1.10 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 & 3 The service users and their representatives are provided with comprehensive information about the service, which enables them to make informed decisions about placing service users in the home. Placements in the home are initially on a trial basis to allow an assessment the service user’s acceptance of the home as a place to live. EVIDENCE: The Statement of Purpose and Service Users Guide were examined and found to provide comprehensive information about the service provided. No new service users had been admitted since the last inspection. However, an examination of the records of the most recently admitted service user had a comprehensive assessment by the referring authority and the manager of the home. An assessment by a psychologist had also been carried out. Following a lengthy assessment period, it was agreed by the home manager and the care manager that this person was appropriately placed. All the service users have profound learning disabilities with severe autism and do not have verbal communication skills. However, there was written guidance for staff about how to communicate with individual service users; for example, “ E uses a wide range of verbal sounds; “pulls you towards desired object”. 18 MARRIOTT ROAD Version 1.10 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 & 9 There is a good standard of care plans to guide staff about meeting service users’ personal objectives. Service users are well supported to make decisions about their lives, based on individual assessments. EVIDENCE: Three care plans were sampled. These contained assessments and objectives of care, together with the actions required to meet objectives. The care plans had been reviewed six-monthly. There were good daily records to support the care plans, and reflect daily activities. There were records of annual reviews by care managers with the service user and their relatives present. Risk assessments were also reviewed at the same time as the care plans. A recommendation is made to include a column in the new care plan format for recording the outcome of the evaluation. The inspector observed staff using various methods of communication with service users; for example, Makaton, and gestures. The acting manager stated that relatives play a significant role in representing service users’ wishes, through regular “Friends of Marriot Road” meetings. 18 MARRIOTT ROAD Version 1.10 Page 10 There were records of risk assessments which addressed key areas of potential risk to service users. These included using public transport and activities within and outside the home. Each service user has an activity programme individually tailored to their needs, likes and dislikes. For example, “E is to be supported privately in his room for sensory sessions”. 18 MARRIOTT ROAD Version 1.10 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) 11, 12, 13, 14, 15, 16 & 17 Service users’ are well supported to integrate with the local community which enables them to enjoy a good quality of life and develop their potential. EVIDENCE: There were records to show service users’ attendance at Barnet College, where groups are run for people who are non-verbal. There is an extensive range of community-based leisure activities provided, including swimming, trips by public transport to places of interest. Daily records showed that service users are supported by staff to visit their families regularly, and there is an unrestricted visiting policy at the home. There were records of service users helping with food shopping and doing their laundry with support from staff. Daily records showed that service users exercised choice about going out and what time to go to bed. The menus showed that varied and well-balanced meals were provided. Fresh fruit was available. There was a record of the food actually eaten by service users, which was well-balanced and varied. A service user was observed cooking his lunch with the support of a member of staff. 18 MARRIOTT ROAD Version 1.10 Page 12 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, 20 & 21 The health needs of service users are attended to from a full range of healthcare professionals. More care and attention is needed in the recording of the administration of medicines. EVIDENCE: At the time of the inspection, none of the service users were requiring personal support. However, the inspector was assured that female service users were always supported by female staff in their personal care. In addition to the home’s own assessment, there was input by a range of health professionals, including consultants, G.Ps and psychologists. The case records also detailed the health appointments attended by service users at dentists and opticians. The accident book showed that accident/incidents were properly recorded. These were mainly assaults on staff by service users, which reflects the very challenging behaviours of some of the service users. There was evidence of risk assessments and assessments of service users by psychologists, who provided guidelines about minimising these behaviours by detailing triggers. 18 MARRIOTT ROAD Version 1.10 Page 13 An examination of the medication and administration records identified an occasion when staff had not signed for the administration of a medicine. The medication policy includes guidance about the covert administration of medicines and arrangements for the storage and recording of controlled drugs. The case files contained information about the wishes of service users’ representatives in the event of the death of the service user. 18 MARRIOTT ROAD Version 1.10 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 & 23 The home records and deals with, complaints appropriately, and there are good systems in place to protect the interests of service users. EVIDENCE: There were six complaints recorded for the past twelve months. The majority of complaints were from the next-door neighbours who were concerned about excess noise from a service user’s room. The complaints book had a record of these events and their outcome. The complaints had been responded to within 28 days. The home should consider sound-proofing this service user’s room to protect the privacy of the neighbours. There were records to show that all the full-time staff had received training in adult protection procedures. There was evidence to show that remaining staff were booked to attend training in May 2005. A new member of staff who was spoken to, was aware of his responsibilities regarding abuse issues and was able to describe appropriate actions to take if there were any concerns. The inspector checked the records of two service users’ personal money. The amount of cash balanced with the records, and receipts of purchases were also available. 18 MARRIOTT ROAD Version 1.10 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, 26 & 30 Since the last inspection, significant improvements have been made to the internal and external structure, and the décor of the home. This has resulted in a safe and attractive environment for service users and staff. There are good standards of hygiene for the protection of service users and staff. EVIDENCE: 18 MARRIOTT ROAD Version 1.10 Page 16 The building is owned by the local authority, which is responsible for major repairs and maintenance. An inspection of the premises was carried out. The exterior of the building has been recently redecorated to a good standard. There is a new carpet on the stairs, and a new door has been installed to provide direct access to the laundry, rather than, as before, going through the kitchen. There is a new floor in the kitchen, and the inspector was informed that quotes are being obtained to replace the worktops. Four bedrooms were visited. They were in good decorative order and the furnishings were appropriate and in good condition. All bedrooms have laminated flooring. As referred to under Standard 22, the acting manager should consider soundproofing a specific service user’s room. A requirement at the last inspection to improve the privacy of a service user’s bedroom had been complied with satisfactorily. There is a cleaner employed and at the time of the inspection, the home was very clean and tidy and there were no offensive odours. 18 MARRIOTT ROAD Version 1.10 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) 31,,33, 34, 35 & 36 The system for vetting staff is poor and could result in the safety and welfare of service users being compromised. EVIDENCE: The staff records contained appropriate job descriptions. The staff rotas showed that there were sufficient numbers staff on duty at all times to meet service users’ needs. One service user has funding for one-to – one staff support. Some records indicated that two staff had started working at the home with an old CRB certificate which did not include a POVA check, and one staff had no CRB check at all. The inspector was concerned that the organisation’s human resources staff did not always ask for POVA checks when applying for CRB certificates. This is an essential check for the protection of service users. In another instance, references had not been obtained. An immediate requirement was made to address these matters, and in the meantime, these staff must be closely supervised until appropriate documents have been obtained. There were records showing that appropriate training was being provided. However, one staff member had been employed for more than six months but 18 MARRIOTT ROAD Version 1.10 Page 18 had not received training in mandatory subjects. A requirement was made to address this. There were good records of regular staff supervision. One staff stated that he found supervision to be helpful in monitoring and improving his performance. 18 MARRIOTT ROAD Version 1.10 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, 38, 39, 41, 42 & 43 The acting manager provides good direction and leadership, with support from a staff team with high morale. EVIDENCE: The acting manager has attained the Registered Manager’s Award and NVQ Level 4 qualification. He has recently applied for registration as the manager of the home. Staff who were spoken to expressed confidence in the acting manager’s ability and commitment to run the home effectively. Comments from relatives of the service users sent to the Commission for Social Care Inspection prior to the inspection, were very complimentary. For example; “the house is extremely well run and very efficient. The staff are particularly kind and helpful. They are also very knowledgeable about autism and are very well trained. I cannot praise Marriot Road staff highly enoughthey go far beyond their remit to help residents and parents.” “Complaints are dealt with very well”. 18 MARRIOTT ROAD Version 1.10 Page 20 There is a development plan for the home and a written budget for all items of expenditure. Reports of monthly inspections of the home by senior managers, have been sent to the Commission for Social Care Inspection as required by Regulation 26. At the last inspection, a requirement was made for a quality audit of the service to be conducted. This has been partially met but has not yet been completed. This requirement is restated. One of the staff has special responsibilities for health and safety and there were records of regular health and safety checks. COSHH materials were stored securely. Fire logs showed that alarm tests and drills were conducted regularly. Certificates of safety for gas and electrical systems were available and a current insurance certificate was on display. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 Standard No 24 Score 3 18 MARRIOTT ROAD Version 1.10 Page 21 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score 25 26 27 28 29 30 STAFFING 3 3 x x x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 3 2 3 18 MARRIOTT ROAD Version 1.10 Page 22 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. 2. Standard 20 34 & 42 Regulation 13(2) 7,9,19 Sch 2 &4 Requirement The Registered Person must ensure that staff sign for all administered medication. The Registered Person must ensure that all staff have two references and CRB/POVA clearance before starting work at the home. This requirement is restated from last inspection. Timescale for action: 31/8/05 The registered person must ensure that a quality audit of the service is undertaken and the results are communicated to the Commission for Social Care Inspection. This requirement is restated from the previous inspection. The registered person must ensure that all newly recruited staff undertake training in the mandatory subjects, within six months of starting work at the home. Timescale for action 30/5/05 3. 39 24 31/8/05 4. 35 31/8/05 18 MARRIOTT ROAD Version 1.10 Page 23 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. Refer to Standard 6 22 Good Practice Recommendations The acting manager should include a column in the new care plan format for recording the outcome of the evaluation. The acting manager should consider sound-proofing a service user’s room to protect the privacy of the neighbours. 18 MARRIOTT ROAD Version 1.10 Page 24 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 18 MARRIOTT ROAD Version 1.10 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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