CARE HOME ADULTS 18-65
Martindale Road, 329 Hounslow Middlesex TW4 7HG Lead Inspector
Robert Bond Unannounced Inspection 31st January 2006 10:00 Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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.V273901.R02.S.doc Version 5.0 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.V273901.R02.S.doc Version 5.0 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 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.V273901.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th September 2005 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.V273901.R02.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Inspector was shown around the home by the Registered Manager. The Inspector met all other staff on duty and all the service users present. The service users were subsequently taken out for the day by the staff. The home is fully occupied and there has been no change of service users since the home opened. There are two staff vacancies at present. The Inspector examined in detail (case tracked) the care records of one service user, and checked a range of other records. The CSCI Inspector inspected the home against 25 of the National Minimum Standards (NMS) for Care Homes for Younger Adults. Of these, the Inspector determined that 14 were fully met, but 11 were only partly met. The Inspector made 13 requirements and 2 recommendations. What the service does well: What has improved since the last inspection?
Person centred plans (PCPs) have been reviewed and a new format is being used. Medication storage and recording has improved, and Health and Safety issues have been corrected. One bedroom has been decorated and a second bedroom was being decorated on the day of the inspection. Although the home has lost the use of the day centre it formerly used, activities in the home have been enhanced by having a music therapist. An aromatherapist is also about to start providing a service within the home. Further activity development is required. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 6 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.V273901.R02.S.doc Version 5.0 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.V273901.R02.S.doc Version 5.0 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): None of these outcomes or standards were assessed on this occasion as no new service user has moved into the home since the last inspection. NMS 5 was assessed and the outcome found to be full met at the previous inspection. EVIDENCE: Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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, 8 and 9. As no service users or their representatives are signing their agreement to the contents of individual care plans, it is not possible to say that service users know that their assessed and changing needs are reflected in their individual plan. Service users are adequately consulted on, and participate in, all aspects of life in the home. As documents such as the handling risk assessment are not regularly reviewed, it is not possible to say that service users are adequately supported to take risks as part of an independent lifestyle. EVIDENCE: NMS6: The Inspector examined a set of case files chosen at random. The Registered Manager reported that there are four files on each service user, a care plan file, an information file, a personal planning book, and a health action plan. There was a well produced care plan on file but it was not dated nor was it signed by the key worker, the manager, the service user, their relative or representative/advocate. Requirement 1.
Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 10 The last formal review of the care plan, with the Local Authority care manager present, had occurred on 21st June 2004. The National Minimum Standards (NMS) require reviews to take place at least six monthly. If the care manager cannot attend, reviews should take place internally at the required intervals. The Registered Manager reported that such reviews take place during the key worker’s professional supervision, but no record of the reviews showed up on the care plan file. Requirement 2. NMS8: The Registered Manager reported that service users are consulted in person centred planning meetings, in drawing up their health action plans, and at monthly service users meetings. NMS9: The information file contained a ‘handling risk assessment’ dated 4th August 2003. There was no evidence that its contents had ever been reviewed since. Requirement 3. The personal planning books for the benefit of service users contain many pictures and are a valuable addition to the person centred planning approach, which is welcomed. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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 and 14 The service users are able to take part in a range of appropriate leisure activities, some of which are in the community. Until an equipment store is created at the home and whilst the snoozelem room remains out of use, it is not possible to report that a full range of appropriate leisure activities are being provided. EVIDENCE: The Inspector examined the ‘activity planner’ charts that are in place to record the daily planned activities of service users. It is unfortunate that the provider’s own day centre had to be closed as no Local Authority day centre places are reportedly available. The knock on effect is that activity materials from the former day centre are now stored in the home’s snoozelum room. A dedicated storage facility is required. Requirement 4. Some efforts have been made to provide alternative activities within the home. Music therapy has started, aromatherapy is about to start according to the Registered Manager, and he is seeking an art therapist. On the day of the inspection, an outing took place. Other activities reported include trips to the
Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 12 park, cinema and public baths. The Registered Manager is investigating the possibility of college places. Recommendation 1. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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): 19 and 20. Service user’s physical and emotional needs are being met in a satisfactory manner. Records of medication administered and the storage of medication were judged to be adequate except that there was an out of date medication list on a service user’s information file, which is not satisfactory. EVIDENCE: NMS19:Each service user has a Health action Plan, an idea that is commended. The Inspector found that individual weight charts were completed monthly, and that records of all health appointments were being kept. NMS20: The Inspector examined the home’s storage of medication facilities, and the records of administration of medication. No substantive errors were found. However a medication report in the care filing system that purported to be current was found to be 19 months old. Records elsewhere showed that a doctor had reviewed the service user’s medication more recently, but the medication record on the information file had not been annotated to show that this review had taken place. Requirement 5. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 14 The Registered Manager reported that no service users are able to administer their own medication Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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 A satisfactory complaints procedure is in place. Service users are not yet adequately protected from abuse. EVIDENCE: NMS22: The complaint that was previously seen to be on file, will be now moved to a ‘staff grievance’ file. A service user-friendly complaints leaflet is in place. NMS23: The Inspector examined staff training records that demonstrated that 5 members of staff had received training by the London Borough of Hounslow in their adult protection procedures, but a further 7 remained to be trained. Requirement 6. The Registered Manager reported that his proprietor has not yet produced for use at the home an updated Adult Protection procedure that makes reference to the role of the Local Authority and of the CSCI in adult protection strategy meetings and investigations. Requirement 7. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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, 25, 26, 27, 28, 29 and 30. The premises are not wholly suitable for their stated purpose due to the lack of storage space, and current lack of a usable Snoozelem room, and lack of an ‘activity centre’ space. The premises are not adequately decorated throughout and the kitchen is not of the required standard. All the other outcomes and standards in this section are fully met, except that the home will not be as clean and hygienic as it should be until the kitchen is furbished. EVIDENCE: The Inspector toured the home in the presence of the Registered Manager. He found it to be sufficiently clean and tidy and safe. It was noted that one bedroom had been decorated and a second bedroom was being decorated. The dining room is also in need of decoration. Requirement 8. The kitchen floor is damaged and the whole room and its equipment must be refurbished. Requirement 9. As reported above, the Snoozelem room is being used for the storage of activity materials. A dedicated storage room is required, (Requirement 4) but a
Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 17 proper activity centre is recommended. Recommendation 2. If this were built as an extension in the garden, the Snoozlem room could become the store. All appropriate doors were locked and no hazards were identified. All appropriate equipped and suitable toilets and baths were available. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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): 33, 34 and 35. The current staff group is not as effective as necessary as two key posts are vacant. The protection of service user’s is not sufficiently robust due to an omission in the home’s practice over CRB’s. Service user’s needs may not be adequately met due to lack of clarity about the training needs of the staff team as a whole. EVIDENCE: NMS33: The Inspector examined the current staff rota. It was in order. The Registered Manager reported that bank staff are used but agency staff are seldom used. He reported two vacancies at present, one as deputy manager and one as senior support worker. These must be filled as soon as possible. Requirement 11. NMS34: The Inspector examined the recruitment file of the latest member of staff recruited. All was in order. However the home did not have a record of the proprietor obtaining a Criminal Records Bureau disclosure check on a long employed member of staff. The request had been outstanding for a long time and must be followed up urgently. Requirement 10.
Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 19 NMS35: The Inspector examined the training records of staff and found that although individual training needs were assessed and recorded during appraisals, these needs were not being drawn together to form a training and development plan for the home as a whole. Requirement 12. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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 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, 38, 40 ,41 and 42 The home is managed to a satisfactory extent and in a satisfactory manner by the Registered Manager but it is not satisfactory that he has to do this to the best of his ability without a deputy manager in post. Service users’ interests are not adequately safeguarded by the policies and procedures the home has in place. The health, safety and welfare of service users is adequately promoted and protected. EVIDENCE: NMS37: The Registered Manager reported that he has obtained the Registered Manager’s Award. NMS38: The Inspector examined the notes of staff meetings that are held monthly. He also noted that staff supervision was taking place. The Inspector Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 21 noted that the home had been running for some months without a deputy manager, which is not satisfactory. NMS40: The Inspector examined the financial records of two service users and found that expenditure from their personal allowances was being recorded and expenditure appeared to be on appropriate items. The Registered Manager reported that one of the service users had a Building Society account still in the name of a former home manager. This must be corrected despite the difficulty reported. Requirement 13. NMS41; As reported above, the home’s policy on Adult Protection is not adequate. (Requirement 6) NMS42: The Inspector checked the homes records of fridge and freezer temperatures, of hot water temperatures, and of fire equipment checks and evacuations. No health and safety concerns were identified. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x 3 2 x Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 2 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Martindale Road, 329 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 2 3 x DS0000022896.V273901.R02.S.doc Version 5.0 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 YA6 Regulation 15 (1) Requirement 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. The registered person shall keep the service user plan under review. The registered person shall ensure that the assessment of the service user’s needs is kept under review and revised as necessary. The registered person must provide adequate storage facilities for the purposes of the care home. Details of any plan relating to the service user in respect of medication, must be kept up to date by the registered person. 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 INSPECTION AS THE TIMESCALE PROVIDED WAS NOT MET.
DS0000022896.V273901.R02.S.doc Timescale for action 01/04/06 2 3 YA6 YA9 15 (2) (b) 14 (2) 01/04/06 01/04/06 4 YA14 23 (2) (l) 01/05/06 5 YA20 17 (3) (a),Sch 3 (m) 13 (6) 01/03/06 6 YA41YA23 01/04/06 Martindale Road, 329 Version 5.0 Page 24 7 YA23 13 (6) 8 9 YA24 YA30YA24 23 (2) (d) 23 (2) (b and c) 10 11 YA34 YA33 19 (4) Sch 2 (7) 18 (1) (a) 12 YA35 18 (1) © 13 YA40 13 (6) The registered person shall arrange the training of all staff to prevent service users from being placed at risk of harm. The dining room must be decorated The kitchen must be refurbished, including the floor. THIS IS A PARTIAL RESTATEMENT OF A PREVIOUS REQUIREMENT THAT WAS NOT MET WITHIN THE TIMESCALE. Current CRB certificates must be obtained for all members of staff. The registered person must ensure that at all times sufficiently qualified, competent and experienced staff are employed in sufficient numbers appropriate to the health and welfare of the service users. In order to provided staff with appropriate training to perform their work, a training profile for the home is required. The registered person shall make arrangements to prevent service users from being placed at risk of (financial) harm. Service user’s financial accounts must not be in the name of someone who no longer works at the care home. 01/04/06 01/07/06 01/07/06 01/03/06 01/04/06 01/04/06 01/04/06 Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 25 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 YA12 YA24 Good Practice Recommendations The Registered Manager should continue in his efforts to find college places and arrange additional therapeutic activities for the service users. A proper activity centre is recommended. This could be in the garden, possibly as an extension to the home. Martindale Road, 329 DS0000022896.V273901.R02.S.doc Version 5.0 Page 26 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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