Inspection on 15/02/06 for Minford Gardens, 35

This inspection was carried out on 15th February 2006.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Minford Gardens, 35 20/06/08

Minford Gardens, 35 28/09/07

Minford Gardens, 35 08/02/07

Minford Gardens, 35 16/08/05

Minford Gardens, 35 28/01/05

Minford Gardens, 35 08/06/04

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 Minford Gardens, 35 Minford Gardens 35 Minford Gardens West Kensington London W14 0AP Lead Inspector Tony Lawrence Unannounced Inspection 15th February 2006 1:30 Minford Gardens, 35 DS0000019138.V280584.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 Minford Gardens, 35 DS0000019138.V280584.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. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Minford Gardens, 35 Address Minford Gardens 35 Minford Gardens West Kensington London W14 0AP 020 7603 8768 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) gill.ritchie@yarrowhousing.org.uk Yarrow Housing Gillian Ruth Ritchie Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation with both board and care is provided at any one time shall not exceed four people with learning disabilities. 16th August 2005 Date of last inspection Brief Description of the Service: 35 Minford Gardens is a registered care home providing personal care and accommodation for four people with a learning disability. At the time of this inspection 2 men and 1 woman were living in the home and there was one vacancy. Notting Hill Housing Trust owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is well located to enable residents to use facilities in the local community and is close to the shops and transport links of Shepherds Bush and Hammersmith. People living in the home have high care needs and intensive support is provided to enable them to participate in activities in the home and the community. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 15th February from 13:30-15:30. The Inspector spent time talking with three service users and the home’s Deputy Manager. The care of two people living in the home was tracked by talking with them and checking care records kept in the home. Three requirements made at the last inspection have been met. The home provides good standards of care and support, but there is a need to reduce the time taken to complete repairs and maintenance. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 6 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 Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 7 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): EVIDENCE: The Key Standard was met at the last inspection in August 2005. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 8 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 The home has good care planning systems but there is a need to make sure that individual’s Person Centred Plans are reviewed regularly. EVIDENCE: Key Standards 7 and 9 were met at the last inspection in August 2005. During this visit the Inspector checked the Person Centred Plans (PCP’s) for 2 people living in the home. One PCP was dated July 2004 and was reviewed in January and September 2005. There is a need to make sure that identified goals are followed up in reviews. For example, one goal was intended to enable a service user to do their own laundry. The review in January 2005 referred to the goal as being partially met but there was no mention of this in the September review. The second PCP reviewed during this visit was not dated but a review had been held in August 2005. Again, key workers should make sure that all records are dated and goals should be clearly stated. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 9 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 and 13. Service users are supported to take part in a range of appropriate activities. EVIDENCE: All Key Standards were met at the last inspection in August 2005. Since the last inspection, one person living in Minford Gardens has moved to another home. The Deputy Manager said that staff from Minford Gardens have been in phone contact and this person seems to be settling in well. During this visit, one person was at home and two other people went to Yarrow’s day service for a relaxation class. The two care plan files reviewed during this visit show that each person living in the home has a programme of activities during the day, evening and weekends. The Inspector felt that good use is made of local facilities, including cafes, pubs and the cinema. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: All 3 Key Standards were met at the last inspection in August 2005. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 11 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): 23. The home has clear adult protection procedures but staff must make sure these are followed at all times. EVIDENCE: Key Standard 22 was met at the last inspection in August 2005. During this visit the Inspector checked the finance records for two service users and incident and accident reports completed by staff. The finance records were checked for the period November 2005 - January 2006. One record was well maintained. The second record showed that a service user spent £54 on clothing as a gift for another person living in the home. The Inspector spoke with the Deputy Manager who was unable to recall what items had been bought, although he believed they were Christmas presents. The Inspector also spoke with the Manager on the phone and she said the clothes were presents for birthday and Christmas. It is a requirement of this report that more detail must be included on receipts for expenditure of large sums of service users’ money. An entry in the communication book said that one service user had bruising or a scratch on their stomach. Staff did not complete an accident form and the Inspector felt that the adult protection procedures should have been followed. The Manager must make sure that staff are aware of the need to understand and follow agreed procedures for the protection of vulnerable adults. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 12 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, 28 and 30. The home provides satisfactory standards of accommodation. Service users’ rooms are well furnished and decorated. EVIDENCE: During this visit the Inspector saw all communal parts of the home and one service user’s bedroom. All parts of the home were clean and tidy. Communal areas were well furnished and decorated and the bedroom was well personalised. The last inspection report highlighted urgent repairs and these have been completed. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 13 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, 33 and 34. The home’s recruitment policies and procedures make sure that only suitable people are recruited to work with service users. Yarrow must make sure that sufficient numbers of staff are available at all times to support service users. EVIDENCE: Key Standard 35 was met at the last inspection in August 2005. When the Inspector arrived at the home, the Deputy Manager was on duty with one bank member of staff. A second Support Worker had phoned in sick an hour before starting his shift. The Deputy Manager said that it had not been possible to arrange cover because of the short notice. A student nurse on placement was also in the home. The home’s Manager was at Yarrow’s Head Office for meetings. During this visit the bank staff and the student nurse supported two service users to attend a relaxation class, leaving the Deputy Manager at home with one service user. The service user who remained at home was quite upset, but it was not possible for the Deputy Manager to spend time with her as he had a meeting with his NVQ Assessor. If staff are unable to work because of sickness, they must make sure they give sufficient notice to enable colleagues to arrange cover. Student nurses should also not be used to cover for permanent staff. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 14 The Deputy Manager confirmed that all staff have a Criminal Records Bureau Enhanced Disclosure and details are kept on the home’s computer. The Manager has also provided the Commission with details of staff CRB checks. The Deputy Manager also said that two staff have completed their NVQ Level 2 qualification training and he and the Manager are completing their NVQ Level 4 managers’ award. Completion of training will enable the home to meet the target for qualified staff during 2006. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 15 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): 41, 42 and 43. Standards of record keeping are good. Some health and safety issues must be resolved and management support to the home must be improved. EVIDENCE: Key Standards 37 and 39 were met at the last inspection in August 2005. During this visit the Inspector checked finance records, the staff rota, communication book and two service users’ care plans. All records were well maintained and up to date. During this visit the Inspector noted that a light fitting in the office was broken and potentially dangerous, the freezer in the kitchen was broken and unusable and the locked front door was not linked to the fire alarm system. The Deputy Manager explained that all three issues have been reported and raised in monitoring visits, but repairs have not been completed. These three issues all present risks to service users and staff and must be resolved without further delay. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 16 The Inspector saw monitoring visit reports for August and December 2005 and January 2006. Reports for September, October and November 2005 were not available in the home. Yarrow managers must make sure that monthly monitoring visits take place and a written report must be sent to the home and the Commission after each visit. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 17 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 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 X 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X 3 2 2 Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 18 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 YA23 YA23 Regulation 17 13 Requirement More detail must be included on receipts for expenditure of large sums of service users’ money. The Manager must make sure that staff are aware of the need to understand and follow agreed procedures for the protection of vulnerable adults. The broken light fitting in the office must be repaired. A new freezer must be provided. The locked front door must be connected to the fire alarm system. If staff are unable to work because of sickness, they must make sure they give sufficient notice to enable colleagues to arrange cover. Student nurses should not be used to cover for permanent staff. Yarrow managers must make sure that monthly monitoring visits take place and a written report must be sent to the home and the Commission after each visit. Timescale for action 30/04/06 30/04/06 3. 4. 5. 6. YA24 YA24 YA24 YA33 23 23 23 18 31/03/06 31/03/06 31/03/06 31/03/06 7. 8. YA33 YA43 18 26 31/03/06 31/03/06 Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 19 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 YA6 YA6 Good Practice Recommendations Goals identified in Person Centred Plans should be followed up in reviews. Key workers should make sure that all records are dated and goals are clearly stated. Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove 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 Minford Gardens, 35 DS0000019138.V280584.R01.S.doc Version 5.1 Page 21 - 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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