Inspection on 04/05/06 for Old Oak Road, 20

This inspection was carried out on 4th May 2006.

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 6 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 28/09/05

Old Oak Road, 20 06/01/05

Old Oak Road, 20 11/08/04

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Edenvale

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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 4th May 2006 09:30 Old Oak Road, 20 DS0000019140.V291482.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 Old Oak Road, 20 DS0000019140.V291482.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. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 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) info@yarrowhousing.org.uk 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.V291482.R01.S.doc Version 5.1 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 28th September 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, one male and four women were living in the home; there is at present a vacancy. 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 provides 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.V291482.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Thursday 4th May 2006; the inspector spent 5.00 hours visiting the home. The Inspector spoke with two of the service users, the Manager, Deputy manager and staff. The Inspector checked the care records of two service users; all four of the service users finance records, medication and all health and safety records. Four of the service users bedrooms were looked at and all communal parts of the home. The home provides a good standard of accommodation that was seen to be clean and tidy on the day of the inspection. There is an issue with environmental repairs on the house not being done, repeat requirements have been set one being an immediate requirement to replace flooring in the top floor bathroom. 6 of the 8 requirements that were set 28/09/05 have been met, 4 new requirements have been made from this visit. What the service does well: What has improved since the last inspection? All relevant documents for new service users including care plans and risk assessments have been completed. All service users have an agreed contract in place. All (PCP) Person Centred Plan reviews have been completed with relevant meetings taking place. The Manager has had a structured annual appraisal. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 6 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. Old Oak Road, 20 DS0000019140.V291482.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 Old Oak Road, 20 DS0000019140.V291482.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): 1,2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The agency provides a clear and comprehensive Statement of Purpose and Service user guide with prospective service users receiving a copy of both documents. EVIDENCE: The inspector checked the Statement of Purpose and Service user guide, both documents were clear with up to date information in place. These documents are available in different formats including pictures if required. All prospective service user needs are assessed with their aims and aspirations looked at to make sure the home is suitable and that staff are adequately trained to be able to meet them. Contracts were in place for all five-service users that were signed and dated. Old Oak Road, 20 DS0000019140.V291482.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): 6,7 and 9 Quality in this outcome area is good. Person Centred Planning (PCP) records are all up to date with a lot of information in place some of the information is in photographs chosen by the service users. These plans are put in place with the service user whose input is sought throughout the process; this ensures the care plan is what the service user requires from the home. EVIDENCE: Two service user files were looked at that had up to date information in place. In each Person Centred Planning (PCP) document there was a lot of information with specific aims for the person to be met in a six month period or before if possible. Review records were all up to date with records showing how aims have been met, in discussion with one service user who stated that they wanted to learn to play the guitar told the Inspector that he has started lessons. This service user spent approximately an hour showing the Inspector his PCP and discussing how he liked living at the home. The service user stated that the staff assist him to be independent as one of his long-term aims is to get married and move out of Old Oak Road into the community with his girlfriend. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 10 Risk assessments were seen to be in place for all of the service users that had been up dated March 2006, relevant actions were in place to minimise any risk. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. Links with the community are good and support to enrich service users social and educational opportunities are in place. EVIDENCE: All of the service users have a full activity plan that was written in their files and also on the notice board in the office and the dinning room/lounge. All of the service users are escorted to go out daily to different venues including The Gate for art and drama classes, relaxation classes, dance classes and also other venues are attended frequently by the service users. In discussion with one of the service users he stated he was happy with all of his activities which he enjoyed doing. The Inspector asked him what his favourite thing was and he answered “dancing and meeting his girlfriend for lunch ”. The home had a TV, DVD and video in the lounge. One service user has a computer in her bedroom that has software installed that enables her to look at photographs to her favourite music, this meets one of her aims. The inspector spent time with the service user looking at photographs of her last holiday. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 12 In discussion with staff and service users it was stated that family members of all the service users are always calling at the home. Most weekends’ service users will either go to visit family and friends or they will come to see them at the home. There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced, this is done at the two weekly residents meetings or in one to one sessions as at times service users may be visiting home when the menu is discussed. The Inspector looked at the meeting book where menus had been discussed by all the service users. A service user stated he enjoyed the food and his favourite was fish and chips on a Friday. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: All of the five service users are assisted with personal care; this is done either in the service users bedroom or in one of the bathrooms. One of the service users requires a hoist to assist her in bathing. One service user spoken with stated he felt that the support he received from staff was enough and that he liked to do as much as possible for himself. All service user health needs are being met in discussion with the Management team and looking at records there are no issues at present. The Manager stated that Healthcare checks are to be completed week of the 08/05/06. 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. There is an issue that old medication is sent back to the pharmacy used. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 14 Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. The complaint procedure is available to all and is written in the Service user guide. There is a procedure in place at the home that is used for protection incidents that is known to service users and staff. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. Service users finances were well managed and accurate records were kept. The finance records for all of the service users were checked. Each contained a record of all income and expenditure. Receipts were obtained for all transactions and the records were regularly balanced and checked by the home’s Manager. The complaints records were checked and there have been no complaints in the last 12 months. The Inspector was shown quality questionnaires that all service users have just completed that ask if they are aware of the complaints, and all have stated they do and would complain if the need arose. One of the service users told the Inspector that he would speak to the Manager if he had a complaint. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 Quality in this outcome area is good. The standard of the environment within the home is good providing service users with an attractive and homely place to live. EVIDENCE: A full tour of the home was given and four of the service users bedrooms were seen, they were all different with the service users individual tastes taken into account. One service user was happy to show the inspector his bedroom and stated he was very happy with the furniture and the décor, his bedroom had a TV and video/DVD player as the service user liked to watch films in his room. There is a lift for access on to the top floor that is maintained annually. There is an issue with remedial works not completed and there are environmental issues that need addressing, requirements have been set to meet these issues. All areas of the home were seen to be very clean, tidy and bright. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 17 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): 32, 34 and 35 Quality in this outcome area is good. Rotas show that sufficient staff are on duty at all times throughout the week. EVIDENCE: The Inspector looked at staff rotas and in discussion with the Management team and looking at routines was happy that the staffing levels at present are sufficient to meet the needs of the service users. Training and development plans are in place for all staff and in discussion with the Management team and looking at records all staff are up to date with training. The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff has up to date checks completed. The Manager confirmed that all new staff complete the care services induction programme developed by the Learning Disability Awards Framework (LDAF). All staff have job descriptions and have clearly defined roles and areas of responsibility outlined. Three staff have completed NVQ training with staff registering to complete when Yarrow have the next intake. The Manager stated that Yarrow does not have sufficient assessors and that other avenues for completing the training are being looked at such as staff attending college sessions. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 18 The Manager confirmed that there are currently two vacancies one for a part time Residential Support Worker and one for a Deputy Manager post; these vacancies are covered by a regular bank staff and the rest of the team working extra shifts. The Inspector checked the supervision records and all staff have regular meetings with up to date records in place. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 19 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, 39 and 42 Quality in this outcome area is good. The Manager is supported by staff in providing a positive inclusive atmosphere. There are environmental health and safety areas that require attention from the Shepherd’s Bush Housing Association. EVIDENCE: The Manager has worked for Yarrow for many years and is a qualified Nurse, the Manager does have to apply for and complete a Registered Managers Award to ensure she is appropriately qualified to run the home. The inspector felt that the home was very open and friendly, staff and service users were working very closely were service users were supported to be independent. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 20 There is an effective quality assurance monitoring system in place that was discussed with the Manager, questionnaires were in the two service users files checked that stated the service users views on the services they receive in the home. Yarrow produces an annual document that is available to prospective service users and any stakeholder’s wishing to see how the organisation works to develop a provision of care that is aiming to improve. All health and safety records were checked and all were seen to be up to date with any maintenance having been carried out. There are large cracks in walls throughout the house that are becoming bigger and need assessing by the Shepherd’s Bush Housing Association who own the property. Water temperatures were seen to be recorded as being low, all thermostats need checking and setting at the right temperature. Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 21 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 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 23 1 3 x x 3 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000019140.V291482.R01.S.doc LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Old Oak Road, 20 Score 3 3 2 x 2 x 3 x x 2 x Version 5.1 Page 22 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 4 5 6 Standard YA20 YA37 YA42 YA42 YA42 YA42 Regulation 13 9 23 23 23 23 Requirement Old medication to be removed from the home and sent back to the pharmacy used. The Manager to apply for a relevant managerial qualification. The flooring to be repaired in the 1st floor bathroom. This is an immediate requirement. Remedial works to be completed on cracks throughout the house. This is a repeat requirement. The shower on the 1st floor to be replaced. Water temperatures are low, all thermostats to be checked and set at the correct temperature. Timescale for action 31/05/06 30/06/06 31/05/06 30/06/06 30/06/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Old Oak Road, 20 DS0000019140.V291482.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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