CARE HOME ADULTS 18-65
Newburgh Road, 13 Acton London W3 5DQ Lead Inspector
Robert Bond Unannounced Inspection 21st February 2006 10:00 Newburgh Road, 13 DS0000027736.V278373.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 Newburgh Road, 13 DS0000027736.V278373.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. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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 8 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.V278373.R01.S.doc Version 5.1 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 31st August 2005 Date of last inspection Brief Description of the Service: Newburgh Road is currently registered for eight adults with learning disabilities that may be associated with a physical disability and/or mental health needs. Only seven service users are actually accommodated, those with physical disabilities being 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 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 kitchen/diner, a combined office and sleeping in room, a laundry, and a large garden with patio suitable for wheelchair users. On the first floor there is a non-smokers lounge, bedrooms, adapted bathroom, and the manager’s 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.V278373.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second of the inspection year and as almost all of the National Minimum Standards (NMS) were inspected against at the previous inspection, this inspection concentrated upon measuring the extent of the home’s compliance with the requirements and recommendations that were made at the previous inspection. Certain key standards were also reinspected against this time. The Inspector toured the home, examined various records, met the Registered Manager, his line manager, two support staff, a domestic member of staff and two service users. On the day of the inspection, the home was technically full but three service users were in hospital for unrelated reasons, and a fourth had gastro-enteritis and was taken to see his doctor. A care plan review was due to take place that afternoon. The Registered Manager reported that there were two staff vacancies that had been advertised, and a third staff member had handed in notice of her leaving. The Inspector assessed the performance of the home against 15 of the NMS, and found that 7 were fully met, whilst 8 were only partly met. The Inspector made 11 requirements (two of which are restated from the previous inspection) and the Inspector made 5 recommendations. What the service does well: What has improved since the last inspection?
The report of the previous inspection contained 14 requirements, 11 of which have been met. The report of the previous inspection contained 7 recommendations, 4 of which have been met. A new user friendly service users’ guide has been produced. Returned medication records signed by the pharmacist are now kept in the home. Staff have been trained in complaints recording. Four staff members have been trained in adult protection procedures. Some parts of the home are cleaner than before. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 6 Archived files and damaged furniture have been removed from the nonsmokers’ lounge. Areas of the home used by smokers have been fire risk assessed, and staff have signed that they have read and understood the home’s fire policy. Fridges and freezers are operating at the correct temperatures. Service users have been consulted about the hot water temperature they prefer. The Registered Manager reported that service users are now more involved than previously in the cleaning and running of the home. 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. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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.V278373.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Prospective service users have good accessible information available to them. There are additional service users, or their representative, who could sign the ‘house agreement’. EVIDENCE: NMS1:The Inspector examined a newly produced service user guide in a format designed to be accessible to the home’s service users. No new service users have moved into the home since before the last inspection and so assessment processes were not inspected this time. NMS5: The Registered Manager reported that not every service user had a signed ‘house agreement’. Recommendation 1. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Service users are adequately consulted on and participate in all aspects of the life of the home. EVIDENCE: NMS8: The Registered Manager reported that service users are now more involved in cleaning the home and in its operation. For example, each service user had been consulted about the temperature of hot water they liked, and this had been recorded. A care plan review was due to happen on the day of the inspection. Care plans were not inspected on this occasion. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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 the following standard(s): 14 The possibility of additional work, education or day time leisure activities should be further explored EVIDENCE: The Registered Manager reported that none of the service users attend a day centre and that the most appropriate local day centre had been closed. The Inspector was concerned about a possible lack of stimulation and asked the Registered Manager to review the possibility of more organised activities, work or education for service users. Requirement 1. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The homes’ records of medication administered are not adequate. EVIDENCE: NMS20: The Inspector examined medication records. The home now has a record of returned medication that has been signed by the pharmacist. The Inspector noted that the MAR sheets produced by Boots the Chemist were not up to date as they included reference to medication that had not been prescribed for some months. Requirement 2. The Inspector found that during the previous few days, there were several gaps in the administration record, and one entry had been placed in the wrong column. Further training of appropriate staff in medication administration is required. Requirement 3. The Inspector found that insulin was being kept in a locked box in the kitchen fridge. A separate medications fridge is recommended. Recommendation 2. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users views are listened to but correct procedures have not been followed Service users are protected from abuse but not all staff have been adequately trained and procedures have not been followed. EVIDENCE: NMS22: The Inspector examined the home’s complaints log which did not record any complaint since before the last inspection. The Inspector had just been told however by the Registered Manager of a complaint that a service user had made against a member of staff. It is accepted that due to the need for confidentiality details of this complaint should not be recorded in the general complaints file, nevertheless written details were not available within the care home for the inspector to examine. Thus it is not known whether the registered provider’s approved complaints policy was correctly followed in this case. Requirement 4. The allegation had not been reported to the CSCI at the time of the complaint either, as required by Regulation 37. Requirement 5. NMS23: The Registered Manager reported that 4 staff had been trained in adult protection but due to difficulties at the Ealing’s Adult Protection Department, some training had been cancelled and hence 4 staff were still awaiting their training. Requirement 6. The Registered Manager also reported that he did not think the complaint referred to in NMS22, had been reported to the London Borough of Ealing’s Adult Protection Service as per Protection of Vulnerable Adults legislation. Requirement 7. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30 The design, decoration, furnishing and equipping of the home is adequate. The home is generally clean enough, except for the internal doors. The home is generally safe enough, except for a trip hazard in the kitchen. Service users bedrooms are suitable furnished Bathrooms and toilets meet individual needs. Maintenance of the property and its contents should be given a higher priority. EVIDENCE: The Inspector toured the premises, including one bedroom at the invitation of the occupant, and found the following. Decoration, equipment and furnishing are adequate. There is a trip hazard in the kitchen around an inspection cover where the floor covering is worn. Requirement 8. The cover to the boiler in the kitchen is stuck on with tape. This is not conducive to creating the required homely atmosphere and the registered person is requested to prevail upon the landlord, Acton Housing Association, to produce a better solution. Recommendation 3. The Inspector observed a number of outstanding maintenance items, namely: lamp shade missing in the smokers’ lounge; loose cupboard door in the downstairs office; broken draft excluder on front door;
Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 14 damaged plaster just inside front door; hinge unscrewed on a bedroom door; hinge unscrewed on an internal fire door; and garden fence at side falling down. Requirement 9. The premises were generally found to be clean, and following the gastroenteritis outbreak that caused one service user to sent to hospital, and other to his GP, areas of the home were being dis-infected. The cleanliness situation is better than at the last inspection, but the Inspector did notice that some internal doors were excessively dirty due to hand marks. Requirement 10. The Inspector tested the call bell system which worked except that one of the staff’s bleeps had a flat battery. This was corrected at the time. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35 The level of training and of trained staff is insufficient. The existence of an effective staff team is put in jeopardy by the current staff changes taking place. EVIDENCE: As reported elsewhere additional training is required in the fields of adult protection and medication administration. The Registered Manager reported that due to trained staff leaving the home, only 3 out of 11 support staff posts (2 are vacant) have an NVQ level 2 or 3 in Care. The national target is 50 . Requirement 11. Three of the home’s staff are however LDAF qualified. The Registered Manager reported that two support workers have recently left the home and a third has given in her notice. It is recommended that strenuous efforts are made to recruit experienced and already qualified support workers to fit the three gaps and to help recreate an effective full staff team. Recommendation 4 Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 42 The home is appropriately managed. The health, safety and welfare of service users are sufficiently promoted and protected. EVIDENCE: NMS37: The Registered Manager is to become the trained NVQ assessor for the home, and is going to undertake the Register Managers Awards and NVQ 4 in care. The Inspector examined records of staff meetings. NMS42: The Inspector checked fridge and freezer temperature records, checked the hot water temperature, and examined a current Legionella certificate. Newburgh Road, 13 DS0000027736.V278373.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 3 2 x 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x 3 x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 2 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 2 x 3 x x x x 3 x Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 YA14 Regulation 16 (2) (n) Requirement The registered person shall consult service users about a programme of activities, work or education, and provide or arrange according to their needs. The registered person must insist that in order to maintain their service contract, the pharmacist produces MAR sheets that are up to date in describing a service user’s current prescribed medication. The registered person must ensure that staff are adequately trained for the work they are to perform (administering medication). The registered person shall supply the Commission with a statement summarising the complaints made during the previous twelve months and the action that was taken. The registered person shall give notice to the Commission without delay of the occurrence of any event covered by this regulation The registered person shall make arrangements by training staff to ensure that service users are
DS0000027736.V278373.R01.S.doc Timescale for action 01/05/06 2 YA20 13 (2) 01/04/06 3 YA20 13 (2) and 18 (1) © 22 (8) 01/04/06 4 YA22 01/04/06 5 YA22 37 (g) 01/04/06 6 YA23 13 (6) 01/05/06 Newburgh Road, 13 Version 5.1 Page 19 7 YA23 13(6) 8 YA24 13(4)(a) 9 YA24 23(2)(b) 10 YA30YA24 23(2)(d) 11 YA35 18(1)(ci) adequately protected from abuse. The registered person shall have in place the required policies and must follow those policies in relation to protection of vulnerable adults (POVA) from abuse or risk of abuse. The floor in the kitchen must be made safe as the registered person must ensure that all parts of the care home are free from hazards to the safety of service users. The premises must be kept in a good state of repair. THIS IS A RESTATEMENT OF A REQUIREMENT MADE IN THE PREVIOUS INSPECTION REPORT. All parts of the care home must be kept clean. THIS IS A RESTATEMENT OF A REQUIREMENT MADE IN THE PREVIOUS INSPECTION REPORT. The registered person shall promote the achievement of 50 of support workers gaining NVQ 2 and 3 awards in care by providing staff with the appropriate assistance to obtain the qualifications. 01/03/06 01/04/06 01/04/06 01/04/06 01/09/06 Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 20 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 3 4 5 Refer to Standard YA5 YA20 YA24 YA33 YA1 Good Practice Recommendations Service users wherever possible, or their representative, should sign the ‘house agreement’. Medication that has to be refrigerated should be kept in a dedicated refrigerator. The kitchen should be made more homely by avoiding having the boiler cover stuck on with adhesive tape. Experienced and already qualified staff should be appointed to as many of the vacant posts as possible. A Variation to the Registration should be applied for as the home is registered for 8 but only ever occupied by 7 service users. Newburgh Road, 13 DS0000027736.V278373.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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