Inspection on 16/08/05 for Minford Gardens, 35

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 15/02/06

Minford Gardens, 35 28/01/05

Minford Gardens, 35 08/06/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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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 West Kensington LONDON W14 0AP Lead Inspector Tony LAWRENCE Unannounced 16 August 2005 08.45 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service MINFORD GARDENS Address 35 Minfords Gardens, West Kensington, London W14 0AP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7603 8768 Yarrow Housing Limited Gillian Ruth Ritchie Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28 January 2005 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 3 men and 1 woman were living in the home. There have been no recent admissions and the group has lived together for the past several years. 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 Shepherd’s 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 G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 16th August 2005 from 08:45 - 14:00. The Inspector spoke with all four service users, staff and the home’s manager. The care received by two people living in the home was tracked by talking with them and staff in the home and reviewing care records. The Inspector felt that people living in Minford Gardens are well cared for and the home provides a good standard of accommodation. Three requirements and three of the four recommendations made at the last inspection have been implemented. 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 G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 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 standard(s) 1, 2, 3 and 5. People living at Minford Gardens are given clear information about the services offered in the home, enabling them to make an informed choice to move into or out of the home. EVIDENCE: The Inspector reviewed the home’s Statement of Purpose and saw that this has been reviewed since the last inspection to include all of the required information. Two service users’ files reviewed by the Inspector each contained a copy of Yarrow’s Resident’s Agreement that details the care and support provided to individuals. Both files also contained a Licence Agreement with Yarrow and the Housing Trust, detailing the terms and conditions of residence. The Manager confirmed that, as part of the home’s referral and admission policies and procedures, a full care needs assessment is carried out by a social worker or other professional. The Manager and staff from the home would also visit and meet people referred to the home to carry out Yarrow’s own assessment of their needs. Staff at Minford Gardens use Yarrow’s system of Person Centred Planning (PCP) to determine each service user’s needs and aspirations. The Inspector checked the PCP file for each of the four service users and saw that each person has an up to date Plan that has been reviewed within the last six months. The Plans each contain clear goals that are based on the wishes of service users and details of how individuals will be supported to achieve these. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 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 standard(s) 6, 7 and 9. The care needs of people living in the home are well assessed and recorded by staff. Each person is involved in developing a care plan that includes their needs and aspirations. EVIDENCE: The Inspector checked the care plan files of all four people living in the home. Each file was well maintained and up to date. Each person has a Person Centred Plan (PCP) that has been developed with support from staff, relatives and professionals. Three of the plans had been reviewed in January 2005. One file included details of a review meeting, but these were not dated. Each plan included input from clinicians from the multi-disciplinary Services for People with a Learning Disability (SPLD), including speech and language therapists, physiotherapists, community nurses, psychologists and social workers. All four PCP’s include clear goals that are based on the wishes of the service user. The plans include clear evidence that service users are involved in developing the care they receive and the organisation and running of review meetings. During this visit the Inspector saw staff working with individual service users. The Inspector felt that all staff respect the wishes of service users and saw many examples of individuals being supported to make choices about aspects MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 9 of their daily lives. Although each person has a programme of weekly activities, these are flexible and service users are encouraged to make decisions and choices about what they want to do each day. During this visit, one service user chose to go shopping with staff, using public transport to get to the shopping centre. Another person also went shopping with staff, walking to local shops. Two people also chose to go to a local Chinese restaurant for lunch. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 and 17. Service users are well supported by staff to take part in a wide range of appropriate activities, in their home and the local community. EVIDENCE: The Inspector saw that each person living in the home has a weekly programme of activities that is included as part of their care plan. Service users and other people involved in their lives are asked about their interests as part of the care plan review process and these are well recorded. The names of contact details of relatives, friends and other important people are well recorded in the care plans and service users are supported to invite people to their review meetings. Staff have a good knowledge of local leisure and community facilities and supported service users to make choices about how they spend their leisure time. Most of the day services available to service users were closed for the summer when this inspection took place. The Inspector saw that staff worked well together to ensure that each person living in the home was occupied and supported to make choices. Care plans also show that each person has a holiday in the UK or abroad. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 11 The standard of risk assessment for each person was excellent. Detailed assessments and support programmes have been completed to maximise each person’s independence. These cover a wide range of activities, including use of the bath and shower, going out, road safety and behavioural issues. The risk assessments are well completed and the Inspector saw that all had been reviewed recently. The home’s dining room and kitchen are well decorated and equipped. Staff told the Inspector that service users are supported to make snacks and drinks and this happened frequently during the inspection. Care plans also show that some service users go to cookery groups at local day services and support staff to make meals in the home. People are also given the choice to eat meals in local cafes and restaurants and this also happened during this inspection. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. The health care needs of people living in the home are well met and there is clear evidence of good working relationships with health and social care professionals. EVIDENCE: Care plans reviewed by the Inspector included clear information about each person’s health care needs. Good links have been made with the clinicians working in the local Services for People with a Learning Disability (SPLD) and the Inspector saw referrals to speech and language therapists, psychologists and community nurses. Assessments and reports from clinicians are used to develop programmes and guidelines for staff. Staff who spoke with the Inspector showed a good knowledge of the programmes for each person living in the home. In particular, staff from Yarrow and the SPLD have developed Pathways to Communication programmes for two people living in the home. The programmes enable service users to communicate their needs in ways that can be understood by staff. Staff told the Inspector that these programmes have been very successful in enabling individuals to make choices and incidents of challenging behaviour have also been reduced. Service users also told the Inspector that they are registered with a local GP and care plans include a clear record of recent appointments with the GP, dentist and other health care professionals. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 13 The home uses a Monitored Dosage System for all prescribed medication and the Inspector checked the medication records for all four service users. The records were very well maintained by staff and no errors were found. The four care plans reviewed by the Inspector included details of the service user’s wishes regarding care when they are ill and in the event of their death. With the agreement of relatives, staff have also supported some service users to subscribe to pre-paid funeral plans. The Inspector felt this sensitive issue was well managed by staff, service users and their relatives. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Service users are cared for safely, but the arrangements for protecting people from financial abuse need to be improved. EVIDENCE: Since the last inspection, there has been one adult protection enquiry involving a service user living in Minford Gardens. Although allegations were not proven, a requirement was made that Yarrow must ensure significant incidents and complaints are reported to the Commission and the local authority. This will ensure that agreed adult protection policies and procedures are followed and service users are protected. Criminal Record Bureau checks have been completed for all staff and the inspector saw a record of these in the home. The four care plan files reviewed during this visit each included a questionnaire designed to gather and record the views of service users on the care they receive in the home. The questionnaire makes good use of photographs to make the information more accessible to service users. The manager confirmed that the survey has been carried out twice. Key workers supported service users to complete the questionnaire for the first time and this has now been repeated, using relatives or advocates to provide more independent support. The Inspector felt that this is a good piece of work that is implemented enthusiastically by the staff team. Checks of the service users’ finance records showed that there has been some inappropriate use of service users’ personal money. This should have been picked up by managers in the home and stricter checks are required to ensure this is not repeated. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 27 and 30. The standard of accommodation is good, providing service users with an attractive and homely place to live. EVIDENCE: 35 Minford Gardens is located in a residential street in Shepherd’s Bush. The kitchen, dining room, lounge, laundry and toilet are on the lower ground floor. The office and two bedrooms are on the ground floor. Two more bedrooms, the shower room and bathroom are on the first floor. The home is not accessible to people with restricted mobility as there are stairs to the front door and internally. Communal areas and service users’ bedrooms are well decorated and furnished. During this visit the Inspector saw three service users’ rooms and all communal parts of the home. A part-time cleaner is employed and all parts of the home are clean and hygienic. The Inspector noted that a toilet seat had been reported as broken on 19th July 2005. The repair has not yet been completed although the toilet is used regularly by service users. Yarrow must ensure that essential repairs are carried out without delay. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 35. The home is well staffed. Service users’ care needs are well known to staff and there are positive relationships between people living in the home and the staff team. EVIDENCE: During this unannounced visit the Inspector spoke with the home’s Manager and care staff on duty. When the Inspector arrived at 08:45 one member of staff was on duty. A second Residential Support Worker started a shift at 09:00 and a third Residential Support Worker started work at 10:00. The Manager and Deputy Manager were on duty from 10:00 – 17:00. The Inspector felt that the home was well staffed to meet the needs of the current service users. The staff team worked well together to ensure that each service user was supported to take part in activities. Staff demonstrated a good awareness of their roles and responsibilities and the roles of other staff in the home. The Manager confirmed that there is one staff vacancy covered by bank staff. Only one member of staff has completed their NVQ Level 2 qualification training, although a second person is due to finish their training shortly. Two other staff have applied to start NVQ Level 2 training later in the year and the Deputy Manager has applied for NVQ Level 4. Although the home will not meet the target for qualified staff in 2005, this should be achieved in 2006. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41 and 42. The home is well managed and service users benefit from consistent standards of care. EVIDENCE: The home’s Manager has completed her Registered Manager’s Award and confirmed that she is due to start her NVQ Care Level 4 later this year. The Inspector felt that some good work has been completed by the Manager and staff since the last inspection to support service users to comment on the quality of care they receive. The manager confirmed that Yarrow is also introducing a Quality Network Action Plan, based on outcomes for service users. The Inspector checked selected care records and standards of record keeping in the home are good. Standards of health and safety recording are good, but there is a need to ensure that weekly tests of the fire alarm system are held and recorded. MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 18 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 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 MINFORD GARDENS Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 2 x G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 Page 19 No 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 23 24 42 Regulation 13 23 23 Requirement Managers must ensure that service users money is not used to pay for staff supporting them. Yarrow must ensure that essential repairs are completed without delay. Weekly tests of the fire alarm system must be held and recorded. Timescale for action 31/10/05 31/10/05 31/10/05 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 Good Practice Recommendations MINFORD GARDENS G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 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 G09-G60 S19138 MINFORD GARDENS UIV244444 160805 STAGE 4.doc Version 1.40 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. 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