Inspection on 30/05/06 for Martindale Road, 329

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Martindale Road, 329 02/07/07

Martindale Road, 329 15/12/06

Martindale Road, 329 31/01/06

Martindale Road, 329 08/09/05

Martindale Road, 329 15/11/04

Martindale Road, 329 14/07/04

Martindale Road, 329 05/02/04

Martindale Road, 329 05/08/03

Martindale Road, 329 21/07/03

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 Martindale Road, 329 Hounslow Middlesex TW4 7HG Lead Inspector Robert Bond Unannounced Inspection 30th May 2006 10:00 Martindale Road, 329 DS0000022896.V289052.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 Martindale Road, 329 DS0000022896.V289052.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. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 tanners@lifeopportunitiestrust.co.ukwww.lifeopp ortunitiestru 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.V289052.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 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. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the day of the inspection all seven service users were in the care home, whilst the kitchen was being refurbished. The Inspector interviewed the Registered Manager and the new Deputy Manager, examined a variety of records and toured the home, meeting and observing staff and service users interacting together. This is a ‘key inspection’ at which the home’s performance measured against the key National Minimum Standards (NMS) was assessed. In total the outcomes of 23 standards was assessed, and the Inspector concluded that 13 outcomes were fully met, whilst 10 outcomes were only partly met. This resulted in the Inspector making 10 requirements, 4 of which are restated from the previous inspection having not been achieved within the original timescale that had been set. The Inspector also made one recommendation. At the previous inspection, 13 requirements had been made, 8 of these have been met, and work is underway with the assistance of the Deputy Manager in bringing the care plans and associated documents up to date. What the service does well: What has improved since the last inspection? The building has been improved by bringing the sensory room back into use, by storing activities materials elsewhere, and by redecoration of the dining room and a further bedroom. The kitchen was being refurbished at the time of the inspection. Additional staff have been trained in Adult Protection, and all training records have improved. A new Deputy Manager has been recruited. Work is scheduled to take place to revise care plans, risk assessments and person centred plans. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 6 Action is underway to further safeguard service users from the danger of potential financial abuse. 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. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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.V289052.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Prospective and actual service users and their representatives do not have sufficient written information on the home available at present. Standard 2 was not assessed as no new service users have moved into the home for several years. EVIDENCE: The Registered Manager produced for the Inspector a revised Statement of Purpose, Service Users’ Guide and draft Contract terms and conditions.. However the documents were not complete as the information on the level of fees remained outstanding. Requirements 1 and 2. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in these outcome areas is adequate. This judgement has been made using available evidence including a visit to the service. Until the home’s care plans, person centred plans and assessments have been rewritten as planned, the associated outcomes are not fully met. Service users’ views are obtained. EVIDENCE: The Registered Manager and Deputy Manager produced a timetable that demonstrated that care plans are due to be redone in a revised format with the involvement of key workers. Person centred plans (PCPs) are also due to be revised with the active involvement of service users. Communication passports are also to be introduced. All the care plans will be formally reviewed thereafter. Service User risk assessments are also scheduled to be redone in a new format. Keyworkers are going to be trained by the Deputy Manager in this process. As the associated requirements made in the previous inspection report have not yet been met, they are restated as Requirements 3, 4 and 5. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 10 Service user’s views are obtained individually, and collectively at monthly home meetings, and via an annual survey process. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16, and 17. Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to the service. Service users have good opportunities to take part in appropriate leisure activities. Relatives are involved in the home. Service users’ rights and responsibilities are recognised. Service users are provided with a healthy diet. EVIDENCE: The Inspector examined a newly devised activity programme that showed planned activities for most service users for most of the day, but not at weekends. The home has a dedicated activities person known as a day service assistant. Her hours are currently 8am to 3.30pm, weekdays only. The Deputy Manager reported that these hours might change to 9am to 4.30pm, which would be sensible in terms of organising activities. The day service assistant is Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 12 able to drive either of the home’s two vehicles but at weekends the number of staff who are qualified to drive a minibus is small, hence a further restraint on weekend activities. See Requirement 6. The Snoozelem/Romper/sensory room has been cleared of boxes and has been refurbished, and staff are to be retrained in its proper use reported the Deputy Manager. The Registered Manager reported on the excellent range of holidays that are enjoyed by service users. The Registered Manager agreed to further investigate the possibility of service users going to college, once their interests have been further ascertained. The Inspector examined a sample food menu. The deputy Manager reported that she is going to revamp the menu in consultation with service users, and the use of Jamie Oliver picture cards, as she wishes to promote Healthy Eating. This initiative is commended. The Inspector observed the service users enjoying their midday lunch with caring and appropriate support being offered by the support staff. Two service users expressed their satisfaction to the Inspector. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and20 Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to the service. Service users receive personal support as they require, and their health needs are met. Service users are protected by the home’s procedures regarding medication. EVIDENCE: The Inspector observed personal care in the form of feeding assistance being offered in an appropriate and caring manner. The Registered Manager reported that the revised care plans and person centred plans will further assist staff in undertaking personal care in a manner that service users prefer. The home has a system of health checks known as OK Health Checks that have now been supplemented by My Health Checks that take onboard the service user perspective. These lead to the writing of Health Action Plans that are preventative in that they identify potential health needs. Hence general medication is reviewed annually by GPs, psychiatric medication is reviewed by Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 14 a consultant psychiatrist, and epilepsy medication is reviewed by community and epilepsy nurses. The Inspector examined the home’s medication records. He found that the medication returned book was not adequate but the Deputy Manager corrected that on the spot. The Inspector also ascertained that the care files did not accord with NMS 20.2 which states, “Service users’ consent to medication is obtained and recorded in the individual Plan”. The two managers agreed to discuss this shortfall with the home’s Service and Development Manager. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23 Quality in these outcome areas is adequate. This judgement has been made using available evidence including a visit to the service. Service users views are listened to and they are protected from abuse. EVIDENCE: The home has a satisfactory complaints procedure in place. No complaints had been recorded since before the previous inspection. No complaints have been made to the CSCI during that time. The home has not yet been provided by the LOT Head Office with a revised Protection of Vulnerable Adults (POVA) policy that covers referral of abuse suspicions to the Local Authority (Hounslow in this case). Requirement 7. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30 Quality in these outcome areas is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and tidy but some further changes are required to make the premises more homely. EVIDENCE: The long awaited refurbishment of the kitchen and its floor was underway at the time of this inspection. The dining room has been redecorated. The bedroom corridor remains institutional but the deputy Manager has ideas for improving it such as putting a picture on the wall, and photographs on doors. Bedrooms are well decorated and furnished. The Sensory room is back in use. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 17 A vinyl sheet bathroom floor was noted to be badly stained and holes were to be seen in it that could harbour infection. It must be replaced. Requirement 8. The home was generally found to be clean and tidy, despite the builders being on site redoing the kitchen. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 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): 32, 34 and 35 Quality in these outcome areas is good. This judgement has been made using available evidence including a visit to the service. The staffing outcomes are fully met. EVIDENCE: The Inspector examined a staff rota that demonstrated sufficient staff being on duty, a reduced use of bank staff and a minimal use of agency staff. This is commended. With the recruitment of a new Deputy Manager, the home only has one permanent staff vacancy, and interviews are scheduled to fill that post. The Inspector examined staff training records that are much better than previous records seen. The Inspector examined the recruitment files of two employees recently taken on. All appropriate checks seem to have been undertaken. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in these outcome areas is adequate. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well run home. Service users’ views are sought but Regulation 26 visits must be monthly. Service users’ rights are safeguarded. Health and safety assessments need to be enhanced. EVIDENCE: The Registered Manager has the Registered Manager’s Award. The Inspector saw evidence of regular staff meetings and regular formal supervision of staff. The Registered Manager reported that the annual quality assurance exercise would take place later in the summer. The Inspector receives periodically copies of Regulation 26 visits to the home that are conducted by the Service and Development Manager. The last one submitted is dated 23rd March 2006. The Registered Manager said a Regulation 26 visit took place last week, but Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 20 when asked by the Inspector said no visit took place in April. Requirement 9 and Recommendation 1. The Inspector examined a random selection of records of expenditure from service users’ monies. The Deputy Manager reported that her name is still on the bank account of some service users from the time she used to work at the home. This anomaly is to be corrected by Court of Protection approval being sought for the relevant service users so that bank accounts can be held for them without accounts being in the names of specific LOT employees. The Inspector checked hot water, fridge and freezer temperature records. He found the risk assessment for the premises was not extensive enough as it did not cover, electricity, gas, COSHH, or the garden. Requirement 10. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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 2 2 x 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 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 x 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 x 3 2 x Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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. 3. Standard YA1 YA1 YA6 Regulation 4 5 15 (1) Requirement A statement of purpose is required that meets the regulations. A service user’s guide and terms and conditions are required that meets the regulations. The registered person shall demonstrate that he has consulted with the service user or their representatives over the drawing up of a service user plan. RESTATED FROM THE PREVIOUS REPORT AS THE TIMESCALE WAS NOT MET. The registered person shall keep the service user plan under review. RESTATED FROM THE PREVIOUS REPORT AS THE TIMESCALE WAS NOT MET. The registered person shall ensure that the assessment of the service user’s needs is kept under review and revised as necessary. RESTATED FROM THE PREVIOUS REPORT AS THE TIMESCALE WAS NOT MET. The registered person shall DS0000022896.V289052.R01.S.doc Timescale for action 01/07/06 01/07/06 01/09/06 4. YA6 15 (2) (b) 01/09/06 5. YA9 14 (2) 01/09/06 6 YA14YA13 16 (2)(n) 01/09/06 Version 5.1 Page 23 Martindale Road, 329 7. YA41 13 (6) consult with service users about their leisure interests and arrange a suitable programme of activities (that includes weekends) 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 TWO REPORTS AS THE TIMESCALES PROVIDED WERE NOT MET. The damaged bathroom floor must be made hygienically safe by replacing the vinyl sheeting. Regulation 26 visits must be at least once a month A risk assessment is required for all appropriate aspects of the premises. 01/09/06 8. 9 10 YA30YA24 YA39 YA42 16(2)(j) 26(3) 13 (4)(a) 01/09/06 01/07/06 01/08/06 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 YA39 Good Practice Recommendations Regulation 26 reports are increasingly being used by the CSCI to monitor the workings of care homes. The format currently in use by LOT is not ideal for this purpose as it does not refer at all to the CSCI Inspections and our requirements. Hence it is recommended that the form is revised so that the Inspector can see at a glance the progress that is being made at the home in meeting CSCI requirements. Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection West London Area Office 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Martindale Road, 329 DS0000022896.V289052.R01.S.doc Version 5.1 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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