CARE HOME ADULTS 18-65
Newburgh Road, 13 Acton London W3 5DQ Lead Inspector
Robert Bond Key Unannounced Inspection 19th October 2006 10:00 Newburgh Road, 13 DS0000027736.V316608.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 Newburgh Road, 13 DS0000027736.V316608.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. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Newburgh Road, 13 Address Acton London W3 5DQ 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 993-5992 0208 993 5992 Ealing Consortium Limited Mr Dominic Shingleton Care Home 7 Category(ies) of Learning disability (0), Learning disability over registration, with number 65 years of age (0), Mental disorder, excluding of places learning disability or dementia (0), Physical disability (0) Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service Users to include Learning Disability Users who are Elderly or have a Physical Disability or have a Mental Health Illness 4th July 2006 Date of last inspection Brief Description of the Service: Newburgh Road is currently registered for seven adults with learning disabilities, that may be associated with a physical disability and/or mental health needs. Those service users with physical disabilities are accommodated on the ground floor. The registered provider is Ealing Consortium and the building is owned by Acton Housing Association who have responsibility for its maintenance. The home is located on a quiet residential street, close to Acton town centre, its shops, facilities and bus links. The building has three floors, linked by an elevator, but access to certain upstairs rooms involves negotiating stairs. On the ground floor there are two en-suite bedrooms that are suitable for service users who use a wheelchair, a large communal kitchenette/diner, an office and staff sleeping in room, a laundry, and a large garden and wheelchair friendly patio area to the rear. On the first floor there is the non-smokers lounge, bedrooms, adapted bathroom, and the managers office. On the top floor are further bedrooms, a bathroom, and the smokers lounge. The staff team comprises a manager, three senior support workers, eight support workers and domestic staff. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was a key inspection that assessed the home’s outcomes only against the ‘key’ National Minimum Standards (NMS) for Care Homes for Younger Adults published by the Department of Health. The outcomes’ analysis showed that 16 expected outcomes were fully met or exceeded, whereas 6 expected outcomes were only partly met. This led to the Inspector making 5 requirements and 2 recommendations. The inspection process involved the Inspector interviewing the Registered Manager, talking to staff and service users, touring the premises and examining a range of records and files. Questionnaire surveys to be returned directly to the Inspector in self-addressed prepaid envelopes were also given to service users and staff, and were sent to relatives and professional staff associated with the home. There have been no changes to the occupancy of the home. The two vacant support worker posts have been recruited to, but the new workers have not yet commenced their duties. The communal circulation areas of the home were being redecorated on the day of the inspection. What the service does well: What has improved since the last inspection?
The registration of the home has been changed so that it now corresponds with the actual number of service users who are resident. Better records of the food actually eaten by service users are now being kept. Satisfactory records of medication that has been returned to the pharmacist are now being kept. The floor surface in the kitchen has been made safe.
Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 6 The Head Office of Ealing Consortium are now sending the care home earlier on in the process the details of recruitment checks that they have undertaken on new starter staff members. New agency employees used within the care home are now required to sign that they have received an induction, and have read and understood the contents of the ‘duty file’. The frequency of formal supervision of permanent employees within the care home has improved. The Registered Manager reports an increase in activities, the variety of activities, and that activities are more geared towards service users wishes than before. 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. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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 Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current service user’s needs are well assessed. EVIDENCE: No new service user has moved into the care home since the previous CSCI inspection. The Inspector therefore examined in detail the risk (moving and handling) assessment on bathing undertaken on one of the existing service users. This was well produced but the Inspector was able to provide the Registered Manager with advice on how to improve risk assessments even further. The Inspector also examined the provider’s moving and handling policy and found it to be excellent. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. 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. Service users are potentially fully aware that their assessed and changing needs and personal goals are well reflected in their individual plan. Service users are well consulted on, and participate fully in, all aspects of life the home. Service users are well supported to take risks as part of an independent lifestyle. EVIDENCE: NMS6: The Inspector examined in detail the service user plan for the service user that he was case-tracking. The service user plan was very well produced but there was no person-centred plan to supplement it. It is recommended that further consideration be given to introducing person-centred plans for those service users who would appreciate them. The Inspector noted that six
Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 10 monthly reviews took place together with consultation with the service user, and that relatives were invited. NMS7: The Inspector noted that service users are involved in review meetings, they attend monthly service user meetings, are asked to complete questionnaires, and are asked their opinions about menu choice, outing destinations, and the colour scheme for decorating the home. NMS9: The Inspector noted that on the care file that was case-tracked, there was a risk assessment concerning that service user going out into the community. The Inspector met the service user and talked to his key worker and it was clear that the service user’s independence was strongly promoted despite the potential risks. Therapeutic risk taking is promoted. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users take part in a wide range of appropriate activities, in the local community, with friends, and their rights and responsibilities are well recognised. Service users are offered a sufficiently health diet, in good surroundings and at appropriate times. EVIDENCE: The Inspector noted evidence that all service users have been consulted about their interests and individual activity timetables have been produced. Service users are involved in laundry and cleaning duties. The Registered Manager reported that some service users visit the local pub or the café on a daily basis, and some service users venture further afield to Ealing and Shepherd’s Bush on shopping trips. A range of sight -seeing trips are organised to museums and Brighton for example. Five service users went on holiday to
Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 12 Blackpool. Two service users attend the Age Concern day centre, and two service users have employment in other Ealing Consortium care homes. The Registered Manager reported that all the service users are registered to vote, all hold keys to their bedrooms, and most service users have positive relationships with family and friends. The Inspector examined the current food menu, and the record of food actually eaten. There were fewer gaps in the latter than at the previous inspection. The Registered Manager reported that weekly meetings were held where service users could express their food choices and that each service user plan included a list of personal food likes and dislikes. Dietary needs are discussed in staff meetings, and one service user sees a dietician. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive excellent personal support in the ways they prefer and require. Service users’ health needs are fully met in appropriate ways. Services users are adequately protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: NMS18: The Inspector examined in detail the support plan for one service user and found that the support plan contained substantial and excellent detail concerning the service user’s wishes about how their personal care needs should be met. The Inspector observed that special equipment was available to be used to assist service users whilst their personal care needs were being met. The Inspector examined records pertaining to the servicing and regular cleaning of a manual and an electric wheelchair. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 14 NMS19: The Registered Manager reported that one GP practice provides a service to all the service users, and that four service users receive depot injections at the home by CPNs. The Inspector examined the health records on file for the service user he case-tracked, and found the service user’s health needs to be very well documented. The Inspector noted that service users are encouraged to eat healthily, OK Health Checks are undertaken annually, and most service users are weighed monthly. Good records are kept of dentist, chiropodist, optician and dietician appointments. NMS20. The Inspector examined a sample of medication administration records and did not note any errors or omissions other than a Regulation 37 report he had previously received concerning an error of administration. The records of medication returned to the pharmacy had been improved. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted on excellently. Service users are well protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints record and found there were two informal complaints and one formal complaint, the distinction being explained within the provider’s complaints procedure. The informal complaints, that concerned one service user complaining about another service user, had been appropriately dealt with by the Registered Manager. The formal complaint concerned a service user reporting that he had been verbally abused by a member of staff. That incident had been reported to the CSCI as a Regulation 37 issue, and had also been reported to the London Borough of Ealing’s Safeguarding Adults section. An internal investigation was taking place at the time of the Inspection. The Registered Manager reported that all staff had received training in the Protection of Vulnerable Adults during the last three years but that 4 staff members were booked to receive updated POVA training in the near future. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is reasonably homely and comfortable but not adequately safe. Service users live in a home that is not sufficiently clean and hygienic. EVIDENCE: The Inspector toured the premises and found them to be appropriately furnished and equipped in a sufficiently domestic manner. The Inspector examined records that demonstrated that equipment was being regularly serviced. All equipment was seen to be functioning correctly. On the day of the inspection, painters and decorators arrived to repaint the communal circulation areas. The Inspector understood that the decorators would be varnishing the internal doors that he has previously reported upon as being dirty.
Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 17 The Registered Manager pointed out a fire door that did not close firmly and said it had been reported for urgent action. The Inspector then identified two other fire doors that did not close firmly. The home’s internal health and safety checks must be sufficient to pick up omissions of this nature. Requirements 1 and 2. The premises were seen to be not sufficiently clean as there was dirt on some floor surfaces, and some areas of internal doors were dusty. The Registered Manager reported that the cleaner was on leave. Recommendation 2. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by adequately competent staff, who are expected to become sufficiently well qualified. Service users are adequately protected by the home’s recruitment policy and practices but not so far as the induction training of temporary staff is concerned. Service users needs are sufficiently well met by staff who will be appropriately trained when additional NVQ’s are obtained. EVIDENCE: The Registered Manager reported that recruitment has taken place to fill the two vacant support worker posts but CRB’s are still awaited. However the vacant posts are being covered without recourse to using long-term temporary agency staff. The Registered Manager reported that 3 out of 7 of the care staff have NVQ level 2 or 3 qualifications in care, a further member of staff is currently undertaking the qualification, and one is due to commence shortly.
Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 19 The Inspector examined the current staff rota. The Inspector examined the induction programme that is applied when new agency temporary staff are accepted into the care home. The programme must contain an instruction on ‘whistle-blowing’ should the inductee ever see something going on that they are unhappy about. Requirement 3 Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. The internal quality monitoring system within the home is not totally adequate. The health, safety and welfare of service users and staff is not adequately safeguarded. EVIDENCE: NMS37: The Registered Manager reported that he is undertaking the A! NVQ assessor’s award and will be commencing the Registered Manager’s Award training in February 2007. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 21 NMS39: The home obtains the views of service users which are taken into account. Thorough Regulation 26 reports are compiled on the home by a manager from outside. What needs to be improved however is internal quality monitoring of health and safety issues so that faulty fire doors, empty first aid boxes, and hot water taps that only run cold, are all identified, reported and rectified quickly. Requirement 2. NMS42: The Inspector checked fridge and freezer temperature records which were satisfactory and he checked hot water temperatures that were not. Sometimes the temperature in an upstairs bathroom was being recorded as being very low. The Registered Manager offered to investigate personally. The matter had not been reported to him by the member of staff recording the low temperature. Requirement 4. As already reported, three fire doors were found that did not close firmly. Requirement 1. In the kitchen, the Inspector found three first aid boxes together, one of them was empty, one contained a list of contents, but one did not. The provision of first aid equipment throughout the home must be rationalised, and their contents must be checked regularly against a written list. Requirement 5. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 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 4 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43
DS0000027736.V316608.R01.S.doc 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 4 16 4 17 4 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Newburgh Road, 13 3 x 2 x x 2 x
Version 5.2 Page 23 Score 4 4 3 x 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 Standard YA24 Regulation 23(4)©(i) Requirement All fire doors must be checked to make sure they close firmly, and adjustments made if they do not. Internal quality monitoring must be sufficient to discover and report health and safety omissions. The induction programme for new staff must include the whistle-blowing procedure. Hot water must be provided in bathrooms. First aid boxes must be properly maintained Timescale for action 01/12/06 2 YA39 12(1)(a) 01/12/06 3 4 5 YA35 YA42 YA42 13(6) 23(2)(j) 23(2)© 01/12/06 01/12/06 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA30 Good Practice Recommendations Further consideration should be given to introducing person-centred service user plans for those service users who would appreciate them. When the cleaner is on leave, further consideration should
DS0000027736.V316608.R01.S.doc Version 5.2 Page 24 Newburgh Road, 13 be given to other means of keeping the premises sufficiently clean. Newburgh Road, 13 DS0000027736.V316608.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Area 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
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