CARE HOME ADULTS 18-65
Martindale Road, 329 Hounslow Middlesex TW4 7HG Lead Inspector
Robert Bond Key Unannounced Inspection 15th December 2006 10:00 Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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 Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Martindale Road, 329 Address Hounslow Middlesex TW4 7HG 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 577 6031 329329@lifeopportunitiestrust.co.uk www.lifeopportunitiestrust.co.uk Life Opportunities Trust Nicholas Horton Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Physical disability (0) of places Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th May 2006 Brief Description of the Service: 329 Martindale Road, Hounslow is a purpose built seven place care home for adults with learning disabilities. Although a two storey property, the service users are all accommodated on the ground floor. Only the office is upstairs. Communal rooms are of a good size and there is a large and secure garden to the rear. All downstairs areas have level access and are accessible to people in wheelchairs. The locality is a residential area near a bus route to Hounslow town centre. Life Opportunities Trust (LOT), who operate the home, is a not for profit organisation. The current fees charged for a place at the care home are £1,308.60 per week. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Inspector spent 3 hours at the care home during which time he toured the premises, interviewed the Deputy Manager, met service users and staff members, and examined a variety of records and files. Questionnaires were sent out in advance of the inspection. Responses were received back from 3 relatives, 2 service users, a GP and a dietician. All were positive. A preinspection questionnaire (PIQ) was also completed by the home. This PIQ, Regulation 37 reports completed by the Registered Manager, and Regulation 26 reports completed by a senior manager of Life Opportunities Trust, were also considered by the Inspector when compiling the inspection report. The home was fully occupied by service users on the day of the inspection, and there was one vacant staff post. The Registered Manager was on sick leave. Equality and diversity were considered during the inspection but no issues were identified. This was a ‘key’ inspection that considered the home’s performance against the key National Minimum Standards (NMS) established by the Department of Health for care homes for younger adults. The Inspector assessed 22 of the NMS, and found that the anticipated outcomes were exceeded in 2 instances, and were fully met in 13 instances, whereas in 7 instances the outcomes were only partly met. This led to the Inspector making 8 requirements. What the service does well: What has improved since the last inspection?
The home’s Statement of Purpose, Service Users’ Guide and Terms and Conditions issued to service users now contain details of the fees charged by the home’s provider. Care plans have been improved, are now signed by a member of staff, and are now regularly reviewed. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 6 A form is now used to record the names of staff involved in reviewing the care plans. The damaged bathroom floor has been repaired. Regulation 26 visits by senior management are now taking place monthly once more. 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. The summary of this inspection report can be made available in other formats on request. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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 Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are no prospective service users at the present time, but good assessments have been undertaken on existing service users. EVIDENCE: The Inspector ascertained that the names of the service users resident in the care home had not changed since the home opened. There are no vacancies. The Inspector examined in detail (case-tracked) the care records of one service user, chosen at random. The Inspector found that a full re-assessment of the service user’s needs had been undertaken as recently as June 2006. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. Service users may not know their assessed needs and goals are reflected satisfactorily in their care plan, as their involvement in drawing up the care plan is not adequately recorded. Service users are enabled to a suitable degree to make decisions about their lives. Service users are adequately supported to take risks but risk assessments are not yet fully in place. EVIDENCE: The Inspector case-tracked (examined in detail) the care records of one service user chosen at random. The care plan was seen to be detailed, clearly produced, and subject to monthly review. The care plan was not however signed by the service user, but the Deputy Manager reported that he was able to sign his name. Requirement 1.
Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 10 The Inspector observed care being provided at two meal times, in a caring and sensitive manner. Service users are involved in decision making, individually at reviews, and collectively in residents’ meetings. The Inspector examined minutes of a residents’ meeting. On the file the Inspector examined, were a manual handling assessment, signed and dated June 2006, and an assessment of coping skills dated 2003. Priority needs and an action plan for achieving them had been revised in June 2006. There was no risk assessment however. The Deputy Manager responded that there were risk assessments on the home’s health and safety file but that these needed to be updated. The Regulation 26 report dated 28/10/06 completed by LOT’s Service and Development Manager also identifies the need for risk assessments of service users to be fully completed. Requirement 2. The Inspector examined the home’s ‘risk taking’ policy and noted that it does promote independence. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to take part to a satisfactory degree in appropriate activities. An adequate number and range of activities take place in the local community. Service users are suitably enabled to maintain family relationships. Service users’ rights and responsibilities are adequately recognised. Service users are provided with a good diet in pleasant surroundings. EVIDENCE: The Inspector examined the home’s activity programme that has been extended to cover evenings and weekends. The programme is primarily home based as no service user attends a day centre or college. None are able to engage in work opportunities. The Deputy Manager however reported outings to Ruislip Lido, Hounslow Urban Farm, the cinema, a canal trip, and a long weekend in Kent. The home owns two vehicles but only the managers are qualified to drive the larger vehicle.
Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 12 The Inspector examined the records of activities undertaken, and also the visitors’ book. The involvement of relatives in the home is limited. The Deputy Manager reported that service users are given the opportunity to have a key to their bedrooms, but none have taken it up. The Inspector observed two meal times that were relaxed and unhurried experiences. The Inspector was sent a copy of the menu with the PIQ, which is satisfactory, and he examined the record of what food the service users actually eat, which is well documented. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans demonstrate well how personal support should be provided. The care records demonstrate well how health care needs are being met. The home’s medication records are very well maintained. EVIDENCE: The Inspector examined a sample care plan in detail and noted that personal care actions for the support staff were recorded within it. The Inspector also examined the daily record on the same service user and was noted that the record was informative and well maintained. The Inspector noted that the care file examined contained an OK Health Check, a monthly weight chart, and a record of health appointments. The file contents also referred to the service users receiving services from GP, physiotherapist, dietician, speech therapist, optician and dentist. The Inspector examined the medication records for all the service users, and for medication returned to the pharmacist. No errors were noted.
Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can feel that their views are adequately listened to and acted upon. Service users are potentially not adequately protected from abuse, neglect and self-harm as the Provider’s policy and procedure on these matters is not complete. EVIDENCE: The Inspector examined the home’s complaints record. It did not contain any entries since before the previous CSCI inspection. The Inspector examined the home’s complaints leaflet. It did not give the current CSCI local office address, and no telephone number was given. The Inspector enquired of the Deputy Manager whether the Provider’s Protection of Vulnerable Adults procedure had been updated to give details of where to make referrals to. She replied that it had not yet been updated. See Requirement 3, which is restated now for the third time. The Inspector ascertained that all but two of the support staff have been trained in POVA this year, and the two managers have received additional training in POVA, now known as Safeguarding Adults. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is sufficiently homely and comfortable, with the exception of one bedroom where the carpet must be replaced. Due to the number of health and safety concerns identified, the home is potentially not sufficiently safe. The home is sufficiently clean and hygienic. EVIDENCE: The Inspector toured the premises in the company of the Deputy Manager. The Inspector noted that the kitchen has been refurbished, a bathroom has been re-floored, and the corridor has had a mirror and pictures hung on the walls. The home was decorated for Christmas and was quite homely and attractive. The home was also sufficiently clean and hygienic. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 16 One bedroom carpet was seen to be ‘rucked up’ and the carpet must be stretched taut, or replaced for health and safety reasons before it becomes a trip hazard. Requirement 4. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by staff members who are sufficient in numbers. Service users are probably adequately protected by the home’s recruitment policy and procedure but the Inspector was unable to verify this. Staff members are adequately trained in so far as mandatory training is concerned. EVIDENCE: The Inspector examined the staff rota and noted that sufficient staff members were working in the home on the day of the inspection. The Deputy Manager reported that the home had one staff vacancy, which was being recruited to at the present time. An applicant had been chosen, subject to CRB clearance. The Inspector was unable to check the recruitment process as the papers were kept at LOT’s head office. The Inspector was unable to check any staff records as they were locked in the Registered Manager’s filing drawer, and he was on sick leave. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 18 The Inspector examined the home’s training records for mandatory training courses, which were satisfactory. The Deputy Manager reported that staff appraisals had not yet taken place this year, and hence training needs analyses for the year ahead were not yet available. A training and development plan based on individual training needs analyses is required. See Requirement 5. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from home that is run in a satisfactory manner. Service users views are collected but there is insufficient evidence that this leads to any changes being proposed. The health, safety and welfare of service users and staff is not sufficiently promoted and protected. EVIDENCE: The Registered Manager has an NVQ level 4 in care and has obtained the Registered Managers Award. The Deputy Manager had previously provided the Inspector with a Regulation 37 report detailing the fact that £30 had been stolen from the home’s ‘activity
Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 20 cash’, a small fund of petty cash kept for immediate payments associated with outings. This fund was only audited monthly, but as a result of the theft, which was reported to the Police, the contents of the box are now checked at every shift handover. The Deputy Manager reported that quality assurance questionnaires are sent out centrally by LOT. The Deputy Manager added that no development or action plan for 2007 was available for inspection. Requirement 6. When asked, the Deputy Manager confirmed that risk assessments of the premises had not yet been completed. The Regulation 26 report dated 28/10/06 confirms this. See Requirement 7, which is restated from the previous inspection report, as the timescale set at that time has not been met. The Inspector noted that quarterly health and safety checks of the premises are undertaken. The Inspector tested the hot water temperature within a bathroom and found it to be within the acceptable range of temperatures. The Deputy Manager reported that a new fire alarm panel had been fitted. The Inspector requested to see the home’s service records for the hoists they had in use, and a copy of water testing for Legionella. The Deputy Manager answered that service contracts such as these were kept at LOT’s head office. The Inspector examined a first aid box. No list of contents was included in the box, hence it would be difficult for the person checking the contents to know what should be in there. Requirement 8. Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 33 x 34 3 35 2 36 X 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 16 17 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000022896.V316394.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Martindale Road, 329 Score 3 4 4 x 3 x 2 x x 2 x
Version 5.2 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. Standard YA6 Regulation 15(2)© Requirement Service users should sign their agreement to their care plan where possible in order to demonstrate that consultation has taken place. Risks for service users have to be identified and eliminated or reduced by the undertaking of risk assessments on all service users. The registered person shall prevent service users being harmed or suffering abuse by having adequate policies and procedures in place. THIS IS RESTATED FROM THE PREVIOUS THREE REPORTS AS THE TIMESCALES PROVIDED WERE NOT MET. The damaged bedroom carpet must be made good. A training plan for the year ahead based on ascertaining individual training needs as part of the staff appraisal system. The views of staff, service users, and other stakeholders must be obtained on a regular basis and used to inform an annual development and action plan for
DS0000022896.V316394.R01.S.doc Timescale for action 01/02/07 2. YA9 13(4)© 01/03/07 3. YA23 13 (6) 01/04/07 4. 5. YA24 YA35 13(4)(a) 18(1)© 01/02/07 01/04/07 6. YA39 21 01/04/07 Martindale Road, 329 Version 5.2 Page 23 the home.. 7. YA42 13(4)(a) A risk assessment is required for all appropriate aspects of the premises. THIS IS RESTATED FROM THE PREVIOUS REPORT AS THE TIMESCALE SET WAS NOT MET. To facilitate the regular checking of the contents of first aid boxes, an approved list of contents must be kept within the box. 01/04/07 8. YA42 12(1)(a) 01/02/07 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 Martindale Road, 329 DS0000022896.V316394.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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