Inspection on 08/02/07 for Minford Gardens, 35

This inspection was carried out on 8th February 2007.

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 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 10 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 15/02/06

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 8th February 2007 11:45 Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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 Robert George Walker Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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. 15th February 2006 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 3 men and 1 woman were living in the home and there were no vacancies. 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.V322463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Thursday 8th February 2007 from 11:45 – 16:00. The Inspector spent time talking with people who live in the home, staff and the Deputy Manager. The care of one person was tracked by talking with them and checking care records kept in the home. The home’s Manager supported all four people living in the home to complete a questionnaire giving their views on the home. Their comments and the comments of one relative / visitor are included in this report. 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. The summary of this inspection report can be made available in other formats on request. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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.V322463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. New service users are well supported when they move into the home. EVIDENCE: Three of the people living at Minford Gardens have lived together for more than 10 years. In April 2006, a new service user moved from another Yarrow project. The pre-admission assessment was very well completed by a member of staff from Minford Gardens, involving the service user and staff from his previous home. The assessment was person-centred and identified the need for the person to move to a quieter environment where his independent living skills could be developed. There was evidence that a number of visits and overnight stays were arranged before the person decided to move. A placement review was held two months after the move and the service user chose to stay at Minford Gardens. There is evidence that the service user’s key worker supported him to complete a pre-review report, giving his views on the move and life at Minford Gardens. During this visit the Inspector spoke with the service user who said that he likes his new home but still enjoys seeing the people he used to live with. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The care plan checked during this visit was up to date and a good example of person centred planning. EVIDENCE: During this visit the Inspector checked the care plan and risk management plan for a service user who moved into the home in April 2006. The care plan followed the principles of person centred planning and clearly detailed the person’s life experiences, abilities, interests, aspirations and support needs. The plan was written in the service user’s voice and there was clear evidence that he had been involved in developing the plan. The care plan file also included very good guidance for staff on how this person prefers to be supported with their personal care. This guidance emphasised the importance of maximising independence and choice in personal care and other activities. The care plan file also included good risk assessments and a risk management plan that covered road safety and possible challenging behaviours at home and in the local community. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Each person living in the home has a programme of appropriate activities in the home and the local community. EVIDENCE: The care plan file checked during this visit included a clear overview of the person’s likes and dislikes, including a description of their ‘perfect day’. The file also included a weekly programme of activities, although staff said that this could be changed if the person chose. The programme included music and dance classes, mini bus trips, cinema and pub trips. The Inspector checked the person’s log book for January and February 2007 and this was evidence that the person regularly went to local pubs and cafes and the cinema. The Inspector did note that the records showed no outside activities during the evenings in January or February, although the person’s assessment and care plan showed that he enjoys evening activities. The home’s rota is evidence that there are usually two staff on duty until 9:00 pm and the manager and staff team must make sure that service users are offered more evening activities. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 10 During this visit, three of the four people living in the home went out with support from staff. One person was supported to go shopping in Ealing, another person went to the cinema and a third person went for a walk to a local café. The fourth person was not well and decided not to go out during the day. The Inspector spoke with this person who said that staff she regularly goes out with staff to local shops and cafes. She also talked about a holiday with staff. Information provided by the Manager before this inspection is evidence that a weekly menu is agreed with service users at the weekly house meeting. The menu includes diets that are needed by individual service users for health reasons. Staff and service users also told the Inspector that the menus are flexible and can be adapted at short notice to meet individual’s choices. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users’ healthcare needs are well met by staff and clinicians. Medication is well managed by care staff. EVIDENCE: The care plan reviewed during this inspection included very clear guidance for care staff on how the service user prefers to be supported with their personal care each day. As with other guidance for staff seen during this visit, the Inspector felt that the personal care guidelines were very person-centred and focussed on maximising the service user’s independence. The service user’s healthcare needs were also well recorded and included assessments by relevant clinicians from the multi-disciplinary Learning Disability Team. There was evidence in the care plan and the daily log that there is good liaison and joint working with the Learning Disability Team. The Inspector checked the medication records for all four people living in the home. The Medication Administration Record (MAR) sheets were all well completed and up to date. The Inspector found no errors in these records. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is Poor. This judgement has been made using available evidence including a visit to this service. Although there have been no formal complaints since the last inspection, the management of service users’ finances must be improved. All staff must also make sure that service users are treated with dignity and respect at all times. EVIDENCE: Information provided by the Manager before this inspection is evidence that there have been no formal complaints since the last inspection. A relative who returned a confidential questionnaire said that they were unaware of the home’s complaints procedures. The Manager must make sure that relatives and other significant people are aware of the complaints procedures. Since that last inspection, there has been one adult protection investigation that resulted in the dismissal of one member of staff for financial mismanagement. During this visit, the Inspector checked the finance records for all four people living in the home. There remains a need to make sure that details of transactions involving service users’ personal money are more transparent. One service user spent £139 on Christmas presents and it was not possible to audit this amount, as the receipts and records completed by staff did not include sufficient detail. The last inspection report included a requirement that staff should record more detail for large items purchased with service users’ money. This is still not happening and the requirement is repeated in this report. Managers and staff must also make sure that service users’ money is not used to purchase items that should be provided by the home. One person living in the home spent £35 on a bedside table and light and another person bought 4 sets of bedding in two months. These items should be provided by the home and service users must be reimbursed. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 13 During this visit, the Inspector heard one member of staff using inappropriate language and tone of voice when talking to a service user. The Inspector discussed this with the home’s Deputy Manager and one of Yarrow’s Care Services Managers. The organisation must make sure that all staff treat people living in the home with dignity and respect at all times. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users live in comfortable accommodation. Some redecoration work is needed. EVIDENCE: During this visit the Inspector saw all communal parts of the home and two service users’ bedrooms with their permission. The home is well located close to local shops and transport links. Accommodation is provided on the lower ground, ground mezzanine and first floors. Staff are aware that one person living in the home is finding the accommodation harder to live in as they get older and their health needs increase. The Deputy Manager confirmed that appropriate referrals have been made to address these issues. The home provides a good standard of private and communal accommodation. Most parts of the home are well furnished and decorated, although the stairs and hallways should be included in the redecoration programme for 20072008. Service users’ bedrooms are well decorated and personalised. During this visit, most parts of the home seen by the Inspector were clean and hygienic, but staff must make sure that their smoking area is kept clean. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is well staffed to meet the care needs of the current service users. EVIDENCE: During this Inspection, the home’s Deputy Manager was on duty, supported by three residential workers. The Inspector felt that this level of staffing was sufficient to meet the care needs of the people currently living in the home. Information provided by the Manager before this inspection is evidence that there are currently vacancies for two residential workers. Pre-inspection information also shows that only 2 staff (35 ) have completed their National Vocational Qualification Level 2 training. The Deputy Manager confirmed that he and the home’s Manager are currently completing their NVQ Level 4 qualification training. Yarrow must make sure that existing residential staff, and any unqualified staff that are appointed to fill the current vacancies, complete their NVQ qualification training without delay. This will enable the home to meet the required standard of 50 qualified staff. The Inspector checked the home’s record of Criminal Record Bureau staff checks and this was evidence that all permanent, agency and bank staff working in the home have a CRB Enhanced Disclosure. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 16 Staff who spoke with the Inspector said that they had access to Yarrow’s training programme. Information provided by the Manager is evidence that recent staff training has included Project Management; Protection of Vulnerable Adults (POVA); Budget Management and Makaton. POVA training is planned for the whole staff team, plus training in dementia care, multi-media and person-centred planning. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 and 43. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed and standards of record keeping are good. The support provided by senior managers must be improved. EVIDENCE: The home has a permanent Manager who transferred from another Yarrow care home. The Manager is registered by the Commission and is currently completing his NVQ Level 4 qualification training. The Inspector saw one quality assurance assessment form on one service user’s care plan file, but this had not been completed. The Manager must inform the Commission of the home’s quality assurance procedures and provide a copy of the latest annual QA report. The Inspector felt that the standards of record keeping in the home are good. The Inspector noted one health and safety issue during this visit. Although fire doors in the home are fitted with door holders activated by the fire alarm Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 18 system, staff must make sure that these are operating effectively and fire doors must not be propped open. Regular monthly monitoring visits by senior managers from within the organisation are not being carried out. The Inspector checked the file of monitoring reports and the most recent report was dated July 2007. The Deputy Manager confirmed that monitoring visits do not take place every month. Unannounced visits must be made every week. If reports are emailed to the home’s Manager, they must be printed and filed for staff reference. This Requirement was made at the last inspection and is repeated in this report. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 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 X 2 2 Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 20 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 YA12 Regulation 16 Requirement The manager and staff team must make sure that service users are offered more evening activities. The Manager must make sure that relatives and other significant people are aware of the home’s complaints procedures. Service users must be refunded money spent on bedding and furniture that should be provided by the home. All staff must make sure that they treat service users with dignity and respect at all times. More detail must be included on receipts for expenditure of large sums of service users’ money. Repeat Requirement. Original timescale of 30/04/06 not met. The staff smoking area must be kept clean. Yarrow must make sure that existing residential staff, and any unqualified staff that are appointed to fill the current vacancies, complete their NVQ qualification training without DS0000019138.V322463.R01.S.doc Timescale for action 30/06/07 2. YA22 22 (5) 30/06/07 3. YA23 17 30/06/07 4. YA23 5. YA23 12 (4) (5) 17 30/06/07 30/06/07 6. 7. YA30 YA32 16 (2), 23 (2) 18, 19 30/06/07 30/09/07 Minford Gardens, 35 Version 5.2 Page 21 delay. 8. YA39 24 (1) (2) (3) The Manager must inform the Commission of the home’s quality assurance procedures and provide a copy of the latest annual QA report for the service. 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. Repeat Requirement. Original timescale of 31/03/06 not met. Staff must make sure that door holders fitted to fire doors are operating effectively and fire doors must not be propped open. 30/06/07 9. YA43 26 30/06/07 10. YA42 23 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The stairs and hallways should be included in the redecoration programme for 2007-2008. Minford Gardens, 35 DS0000019138.V322463.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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