Inspection on 28/09/05 for Old Oak Road, 20

This inspection was carried out on 28th September 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 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Old Oak Road, 20 09/07/09

Old Oak Road, 20 20/08/08

Old Oak Road, 20 31/01/08

Old Oak Road, 20 16/07/07

Old Oak Road, 20 04/05/06

Old Oak Road, 20 06/01/05

Old Oak Road, 20 11/08/04

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Chatsworth Care - Dawson House

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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 Old Oak Road, 20 Old Oak Road 20 Old Oak Road Acton London W3 7HL Lead Inspector Jacqueline Derbyshire Unannounced Inspection 28th September 2005 09:30 Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Old Oak Road, 20 Address Old Oak Road 20 Old Oak Road Acton London W3 7HL 020 8740 1296 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) Yarrow Housing Ms Martyne Rosaria O Reilly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 6 people with learning The number of persons for whom residential accommodation with both board and care is provided at any one time shall not exceed 6 people with learning difficulties two of whom may have a physical disability 1st June 2005 Date of last inspection Brief Description of the Service: 20 Old Oak Road is a registered care home providing accommodation and personal care for six men and women with a learning disability. At the time of this inspection, two men and four women were living in the home. The home is located in a residential area of Acton and there are good transport links with the community facilities in Hammersmith and Shepherds Bush. Shepherd’s Bush Housing Association owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home provided a very good standard of accommodation. It was fully accessible to people with a physical disability and people with limited mobility, including those who use a wheelchair with lift access to the top floor. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 28th September 2005; the inspection took 3.30 hrs to complete. The inspector spent time talking to service users, staff and the management team. Records and documents were checked and a full tour of the home was given. 5 of the 7 requirements set in June 2005 have been met, there were 6 new requirements set, 3 of the requirements have been set as immediate requirements with a 7 day time period to complete. What the service does well: What has improved since the last inspection? What they could do better: All relevant documents for new service users including care plans and risk assessments need to be completed. All service users to have an agreed contract in place. All (PCP) Person Centred Plan reviews to be completed on all service users. The Manager to have a structured annual appraisal. Remedial works on cracks in walls throughout the house to be repaired. The 1st floor bathroom flooring to be repaired. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 6 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. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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): 2 and 5 The Manager must ensure that prospective service users have a full needs assessment prior to placement to ensure that all needs can be met. Contracts must be in place for all service users. EVIDENCE: The inspector checked two service user files one of them being the new service user. All relevant information was seen to be in place for one, however there was very little information on the new service user. There was no needs assessment record completed by social services prior to the placement. In discussion with the Manager it was stated that the service user had visited the home on introductory visits prior to the placement. The new service user had not signed an agreement contract; the manager must ensure all service users have a signed contract in place. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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): 6 The Manager must have in place a care plan for all service users to ensure that the care provision meets the service users needs. EVIDENCE: The inspector checked the records of two service users only one of which had a care plan. The Manager must ensure that a care plan is in place for all service users. The care plan should be generated from the original assessment. The Manager must follow the correct procedure when new service users are being placed in the home to ascertain that the home is the best place for the service user where their needs can be met. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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): 12,14,15 and 17 The home has activity plans in place that show a varied mix of activities that is suitable for each of the service users needs. EVIDENCE: All of the service users have a full activity plan that was written in their files, in discussion with 2 service users they stated they were happy with the activities they did. In discussion with the Manager and staff it was stated that they try to vary every service users activity plans. The service users are taken out daily to various day centres and clubs. Outings to local shops, cinemas and the bowling alley seem to be the favourite places at present. Activities in the home are also excellent with service users having activity boxes with pictures of activities that they can choose from. There is a TV and video in the lounge. All of the service users have visitors, service users stated tat they felt their visitors were always welcomed by staff at the home. Meal times are generally flexible to fit in with activities and individual choices. There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 11 The inspector saw fresh fruit and vegetables that are provided daily to all service users. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 the following standard(s): 20 The systems for the administration of medication are good with clear arrangements in place to ensure service users medication needs are met. EVIDENCE: The Inspector checked the medication administration records for all of the people living in the home. Overall the Inspector felt that the standard of medication recording was good with all staff following the medication procedure. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 13 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 The home has made appropriate use of adult protection procedures. EVIDENCE: The home has a protection procedure in place, discussions with staff members showed that they were aware what to do if an incident occurred. Service users stated that they would speak to the Manager or a member of staff. The inspector checked the finance records of all 6 service users, all monies were correct with daily expenditure logs and receipts for all purchases. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home provides a clean comfortable environment for service users. EVIDENCE: A full tour of the home was given and all of the service users bedrooms were seen, they were all different with the service users individual tastes taken into account. All communal areas were seen to be well decorated, clean and tidy. There is a lift for access on to the top floor that is maintained annually. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 36 The home has adequate staff on at all times ensuring that the service users needs are met. The Management team have regular supervision with all staff; the organisation must ensure that the Manager receives an annual appraisal. EVIDENCE: The inspector checked the homes staff rota and there are sufficient staff on duty at all times ensuring that service users needs are fully met. Staffing at the weekend is now also sufficient to enable service users to go on outings if they choose to do so as written in their care plans. In discussion with the Manager and checking documents it was apparent that all staff have regular supervision and long-term staff have an annual appraisal. There is a need for the Manager to have annual appraisal meetings from the organisation. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 Manager is well supported by staff to ensure all health; safety and welfare issues are met. EVIDENCE: The inspector felt that the home was very open and friendly, staff and service users were working very closely. Records were checked for the fire alarm and fire drills, all other records ensuring the health, safety and welfare of service users were checked. In discussion with the Manager and staff it was stated that all staff are up to date in health and safety training. There is an ongoing issue with remedial work on cracks in the walls throughout the building, these need to be checked and repair work completed. The flooring in the 1st floor bathroom needs to be replaced or repaired to avoid any service users or staff having an accident. Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Oak Road, 20 Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 x DS0000019140.V252940.R01.S.doc Version 5.0 Page 18 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 2 3 Standard YA5 YA6 YA6 Regulation 14 15 13 Requirement All service users to have a contract. This is an immediate requirement A care plan to be put in place for the new service user. This is an immediate requirement An assessment of risk to be completed on the new service user. This is an immediate requirement All service user (PCP) Person Centred Planning reviews to be completed. The organisation to ensure the manager has an annual appraisal meeting. This is a repeat requirement. Remedial work to be completed on cracks throughout the house. This is a repeat requirement. The flooring to be repaired in the first floor bathroom. All new service users being placed by social services to have a full needs assessment prior to placement to ensure all needs can be met Timescale for action 05/10/05 05/10/05 05/10/05 4 5 YA6 YA36 15 18 31/10/05 31/10/05 6 7 8 YA42 YA42 YA2 23 23 14 31/10/05 31/10/05 28/09/05 Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Oak Road, 20 DS0000019140.V252940.R01.S.doc Version 5.0 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. 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