Inspection on 14/06/05 for Peel Way

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Peel Way 18/09/07

Peel Way 15/12/06

Peel Way 05/10/05

Peel Way 15/05/05

Peel Way 24/02/05

Peel Way 26/08/04

Peel Way 19/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 PEEL WAY 6 PEEL WAY HAROLD WOOD ROMFORD RM3 OPD Lead Inspector EDI OFARRELL Unannounced Inspection 14 June 2005, 10.45 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 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 Stationary 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. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Peel Way Address 6 Peel Way, Harold Wood, Romford, Essex, RM3 OPD Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01708 386478 01708 345448 The Avenues Trust Ms Beverley Pace CRH - Care Home PC - Personal Care 6 6 Category(ies) of LD - Learning Disabilities registration, with number of places PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24/02/05 Brief Description of the Service: 6 Peel Way is a purpose built home for six adults with severe learning disabilities, situated in Harold Wood, Romford. It is a detached, two storey house, with parking space to the front, and an enclosed garden to the rear. There is an open plan lounge/dinning area, conservatory, kitchen, and utility room on the ground floor, as well as two bedrooms, each of which have an ensuite toilet and bath. The remaining four bedrooms are on the upper floor, and each has an ensuite toilet, and share a bathroom. There is a ramp to both the front and the back entrance, but no lift to the upper floor. The home is run by The Avenue Trust, a voluntary organisation that runs other similar homes in the South East. There are good local transport links, and the home also has its own minibus. Personal care is provided on a 24-hour basis, with health care needs being met by visiting professionals, or staff accompanying service users to appointments. The home is currently implementing a Person Centred Planning system, in line with central government policy in relation to people with learning disabilities, as outlined in `Valuing People. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday from mid morning to early afternoon. Four of the service users were on their annual holiday at Butlins in Minehead, accompanied by the manager and other staff. The remaining two service users were at home, but, due to the level of their disabilities, it was not possible to obtain their views of the service. Care records were examined, along with other documents, such as records of accidents, menus, and records of staff and resident meetings. The building was toured, both inside and out. Several aspects of the care provided by the home were discussed with the senior support worker on duty during the visit. Because the majority of service users, and the manager and staff were away it was not possible to fully assess many of the Standards, and only those elements where action had been required following the last visit were looked at. What the service does well: What has improved since the last inspection? What they could do better: The new care planning system needs to be completed, and to include full risk assessment, particularly where restrictions may have to be in place. The record of the food provided for service users needs to be more comprehensive, PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 6 so that it is clear that they are getting a varied and well balanced diet, that suits their needs. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 1 & 5 The manager has made the amendment to the Statement of Purpose that was required by the last inspection, so that the information about the qualifications and experience of staff is now accurate. Each service user has an individual written contract. EVIDENCE: The current Statement of Purpose was examined and was found to contain upto-date information about the qualifications and experience of the staff team. The Service User Guide was also looked at and, as at previous inspections, found to be a useful document and accessible to the service users, as it uses plain language and pictures. Standards 2 to 4 were not assessed, as there have been no new admissions since the last inspection. There are systems in place for pre-admission assessment and visits. A standard contract is in place for each service user. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 6, 7, 8 & 9 Service users know that their individual needs are met on a day-to-day basis, but assessment, including risk assessment, and care planning paperwork has not yet been fully completed. EVIDENCE: Two care plans were examined, and the findings discussed with the senior support worker. The current care plans are as they were at the last visit when the report commented on there being a need for more detail. A new system of Person Centred Planning (PCP) is being introduced, and a complete set of the documents is in each service user’s file. This new system is very user friendly, using photos and pictures to describe, in the first tense, each persons’ likes and dislikes, means of communication, and circles of support etc. The assessments have started but have not yet been completed. In addition risk assessments are very limited, and do not always provide a picture as to how decisions about care have been arrived at. In looking through the current plans and daily logs it is obvious that staff are aware of service users’ needs and meet them on a day-to-day basis. As PCP is a relatively new concept in learning disability services, and staff have needed to have training prior to carrying out the assessments and developing PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 10 the new plans the Commission has set new timescales for three Requirements brought forward from the previous inspection and expects at the next visit to find that all six service users plans have been completed, and are being regularly reviewed. These are Requirements 1 to 3. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 17 The service users enjoyment of mealtimes may be affected by the behaviour of one service user. Only partial records are being kept of the food offered to the service users. EVIDENCE: The content of the fridge was checked along with the past three weeks menu. There was fresh meat, poultry, vegetables and salad in the fridge, and fresh fruit in a bowl in the kitchen. The menu does not include the breakfast, and simply states `choice’ for supper. The home must maintain an accurate record of the food that is provided and taken by service users. This is so that it is possible to see if the diet offered to service users is balanced and meets their nutritional needs. This is Requirement 4. One service user suffers from chronic constipation and there is a care plan in place, which includes the provision of a high fibre diet but it is not possible from the current records to assess if this is being followed. One of the service users takes food from the kitchen, and from other peoples’ plates, and there is a care plan in place for staff to follow when this happens, but this lacks some details. For example it states that when he takes other PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 12 service user’s food he must not be allowed to eat it. This must produce a confrontational situation, but there is no plan for how staff should consistently deal with this. Refer to Requirements 1 & 3. The effect on other service users was not documented, nor was it possible to observe due to most of the service users being away PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 18, 19, 20 & 21 Service users receive personal support in the way they prefer and their physical and emotional health needs are met on a day-to-day basis because the staff team know the service users very well. The introduction of Person Centred Planning will build on this knowledge and will provide much more detailed care plans, and risk assessment. The home’s policies and procedures for dealing with medication are now being following correctly affording protection to the service users. EVIDENCE: Personal and healthcare needs are identified in the current care plans, and there was evidence of specialist in-put where required. This includes visits by the district nurse, who maintains a record of visits at the home. One service user, who is epileptic, has an erratic pattern of seizures, and the records showed that staff had been alert to changes and promptly reported these to medical staff. There were clear guidelines on file for how staff should respond to two different types of seizures, and the service user is being seen on a regular basis by the specialist consultant. The new assessment and care planning system covers health and personal care needs comprehensively but needs to be fully completed on all service users. Refer to Requirements 1 to 3. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 14 Two medication administration charts and the medicine cupboard were checked and found to be in order. The home uses the blister pack system and both medication and charts had been taken on holiday in a locked case for the four other service users. Medication is monitored by the GP and there was evidence of regular review and changes in prescription in response to changing need. The home has involved relatives in identifying how the death of each service user will be responded to, and written details were held on both files seen. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 22 & 23, only as they relate to Requirements set at the previous inspection. The complaint procedure needs to be amended so that complainants know about the Commission, and how to contact inspectors. Not all staff have yet received adult protection training. EVIDENCE: As four of the service users, the manager and most of the staff were away on holiday it was not possible to fully assess these Standards. In response to a Requirement set at the previous inspection a complaint log has been set up, though no complaints have been received since the last visit. The complaint procedure needs to be updated as it still refers to the previous Commission, as does the complaints leaflet. This is Requirement 5. Six copies of a new leaflet about the work of the Commission, with contact details, were given to the senior support worker, who agreed to give a copy to each service user’s relative. A Requirement was set at the previous inspection that all staff must receive adult protection training. The training records were examined and showed that some staff still had not had this training. A new timescale has been set for Requirement 6. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 The home is well decorated and maintained providing a pleasant and homely environment in which to live. Bedrooms are furnished to suit each service user’s needs and to promote their independence. Shared space has been enhanced by the addition of a conservatory. The home is clean and hygienic. EVIDENCE: The building was toured, including four of the bedrooms. All areas were very clean and tidy, and the two staff on duty were taking the opportunity of four service users being away to deep clean the kitchen and communal areas. The home has a light, airy and pleasant atmosphere, being well decorated and maintained. Furniture is domestic in nature in both communal areas and bedrooms. Each of the bedrooms seen was furnished to meet the needs and wishes of each service user. In checking the service users’ money later during the visit it was noted that one service user had purchased a mattress and a bath mat. These are both items that the home should be providing not the individual service user. This is Requirement 7. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 17 The two bedrooms on the ground floor have ensuite toilet and bathroom, and the four on the upper floor have ensuite toilets, and share a bathroom. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 as they relate to Requirements set at the previous inspection. It was not possible to fully assess these Standards during this visit, but the records seen suggest that the service users are supported by competent staff. EVIDENCE: Records of staff meetings and training were examined and discussed with the senior support worker. Due to the service users and staff being on holiday it was not possible to fully assess these Standards. Three Requirements and one Recommendation set at the previous inspection were checked with the following results. Information about CRB checks and proof of identity are not held in the home, as the Human Resource team at the organisation’s head office deals with them. They were contacted by phone during the visit and confirmed that all CRB checks had been received, and that all staff files are being reviewed to ensure that all required information of Schedule 2 of the Care Standards Regulations 2001 is included. The senior support worker stated that where an announced inspection was to be carried out then arrangements could be made for the files to be at the home for inspection. They are not kept at the home for reasons of confidentiality as filing cabinet keys are held by whoever is in charge of each shift, and this would mean that staff had access to each other’s private details. The Commission needs to be assured that all required checks PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 19 have been carried out so once the review of staff files is completed the Responsible Person must confirm this to the Commission in writing. This must include a list of staff, confirmation that a CRB check has been undertaken, and which documents have been accepted as proof of identity. This is Requirement 8. The Requirement set at the previous inspection regarding 50 of care staff achieving NVQ level 2 in care by the end of 2005 has been taken forward as Requirement 9, with the original timescale. The senior support worker confirmed that care staff are now receiving formal supervision at least six times a year, but the supervision records were not checked on this visit to confirm this, or to judge the amount of detail being recorded, as recommended at the last inspection. This will be checked on further at the next visit. The records maintained by staff in relation to service users indicated a knowledgably and competent staff team. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 40 & 42 The home appears to be well managed, with a focus on the best interest of service users. Health & Safety risk assessment is in place, but does not cover all duties being undertaken by staff. EVIDENCE: The Requirement set at the last inspection for the manager to acquire NVQ level 4 in management and care or the Registered Managers Award has been taken forward as Requirement 10 with the original deadline. At the last inspection when the money belonging to the service users, which is held in the safe, was checked discrepancies were found. Two sets of records were checked on this visit and the money counted. In both cases it was correct. PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 21 A senior manager is now undertaking monthly visits to the home, and reports are being forwarded to the Commission on a regular basis. Accident records were checked along with Health and Safety risk assessments. During the visit one member of staff was cleaning the kitchen, using stepladders. They were not appropriately dressed for this as they were wearing wedged heel sandals and a long skirt, both of which can be hazardous when climbing ladders. Neither was there a risk assessment for this activity, though there were for the more routine cleaning duties. This is Requirement 11. This was immediately discussed with both members of staff on duty during the visit, and the activity was stopped. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x 3 Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 PEEL WAY Score 2 2 Standard No 24 25 26 27 28 29 Score 3 3 2 3 3 3 Version 1.20 Page 22 G55 S0000015599 Peel Way V225726 140605 Stage 4.doc 8 9 10 LIFESTYLES 3 2 x Score 30 STAFFING 3 Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x Standard No 37 38 39 40 41 42 43 Score 3 x x 3 x 2 x PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 & 19 Regulation 15(1) & 12 Requirement Timescale for action 30/09/05 2. YA6 & 19 3. YA9 & 19 4. 5. YA17 YA 22 6. 7. YA23 YA26 It is a Requirement that more detailed information is provided in care plans about management of aggressive or self-harming behaviour. Previous timescale of 24/05/05 not met 15 & 12 Care plans must be reviewed on a regular basis, of at least once a month or when changes occur in the service users circumstances if it is sooner than the month timescale. Previous timescale of 24/05/05 not met. 12, 13, 14 The home must have more & 15 detailed risk assessments for all service users. Previous timescale of 24/05/05 not met. 17 (2) The Registered Manager must Schedule keep an accurate record of all 4. 13 food provided for service users. 22 (7) The complaint procedure and leaflet must be updated to include the contact details of the CSCI. 13 (6) All staff must receive adult protection training. Previous timescale of 24/05/05 not met 16 (2) c The Registered Manager must ensure that the home provides appropriate bedding, including matresses, and that service G55 S0000015599 Peel Way V225726 140605 Stage 4.doc 30/09/05 30/09/05 31/08/05 30/09/05 31/10/05 31/08/05 PEEL WAY Version 1.20 Page 24 8. YA34 9 & 19 Schedule 2 9. 10. YA35 YA37 18 9 11. 42 13 (4) users money is not used for this type of purchase. The Responsible Person must confirm in writing that all staff files contain CRB checks and proof of identity. This must include the name of each staff member and the documents that have been accepted as proof of identity. 50 of care staff at the home must have achieved NVQ level 2 in care by the end of 2005. The manager must acquire NVQ level 4 in management and care or the Registered Managers Award. Where staff undertake duties that may pose a risk to their health and safety, such as climbing ladders, full risk assessment must be carried out and recorded. 30/09/05 31/12/05 31/12/05 14/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford, Essex IG1 4PU 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 PEEL WAY G55 S0000015599 Peel Way V225726 140605 Stage 4.doc Version 1.20 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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