Inspection on 17/05/05 for Percy Road, 97

This inspection was carried out on 17th May 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Percy Road, 97 12/02/09

Percy Road, 97 09/04/08

Percy Road, 97 29/06/07

Percy Road, 97 18/10/05

Percy Road, 97 15/12/04

Percy Road, 97 18/05/04

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

CARE HOME ADULTS 18-65 PERCY ROAD 97 Percy Road Shepherds Bush LONDON W12 9QH Lead Inspector Tony Lawrence Announced 17 May 2005 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. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Percy Road Address 97 Percy Road 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) 020 8743 0044 Yarrow Housing Ltd Ms Sonia Gray Care Home 4 Category(ies) of Learning disability (4) registration, with number of places PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15 December 2004 Brief Description of the Service: 97 Percy Road is a registered care home providing accommodation and personal care for four people with a learning disability. At the time of this inspection, two men and two woman were living in the home and there were no vacancies. The property is owned by the Threshold Tennant Trust Housing Association and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is located in a quiet residential street in Shepherd’s Bush, close to shops and public transport. Accommodation is provided on 3 floors. There is a lounge, kitchen/dining room, one bedroom, shower room/WC and laundry room on the ground floor and a small garden/patio to the rear of the home. The office, two bedrooms and a bathroom are situated on the 1st floor and the remaining bedroom is on the 2nd floor. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on Tuesday 17th May 2005 from 09:15 – 14:45. The Inspector spoke with service users, staff and the home’s Manager, toured the building and checked care records. People living in the home are well cared for and are supported to be as independent as possible. Two of the three requirements made at the last inspection have been met. One requirement is repeated. Two service users, six relatives and three professionals returned questionnaires and their comments are included in this report. What the service does well: What has improved since the last inspection? 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. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 6 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 PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 7 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) 2, 4 and 5. The home has clear procedures for the referral of new service users and individuals are fully involved in making an informed choice to move into the home. EVIDENCE: The inspector felt that the home’s Manager and staff were clear about the organisation’s policy and procedures for filling vacancies in the home. The Manager confirmed that, since the last inspection, one new service user has moved into the home. The Inspector spent some time talking with this service user and they said that they had visited the home before moving in. They also said they had spent some time in another care home, but preferred Percy Road. The person’s care plan file included a care needs assessment that had been completed by two managers from Yarrow Housing and Care. The assessment was well completed and detailed the person’s strengths, likes, dislikes and aspirations. Staff from Percy Road explained that the assessment was used to develop a Person Centred Plan after the person moved into the home. The service user’s care plan file also included a copy of the Licence Agreement that details the terms and conditions of residence and the facilities provided in the home. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 8 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 and 9. The home has a good system of person-centred care planning and service users are fully involved in defining the care and support they receive. EVIDENCE: The Inspector reviewed the care plans for two people living in the home. Staff at Percy Road have introduced a system of person-centred planning that concentrates on the service users’ aspirations and how these will be met, in the home and the wider community. Key workers support individuals to develop a planning book that is used to record significant people, places and events in the person’s life. The Inspector felt that both planning books made excellent use of photographs to illustrate the major issues to be included in the care plan. Staff told the Inspector that the use of photographs and clip-art pictures had enabled service users to become more involved in deciding what issues are discussed at care plan meetings and who they want to attend. Both care plans included clear goals that aim to develop and maintain individual’s independence. The goals covered a wide range of issues, including improvement of a person’s cooking skills, obtaining a passport and arranging a foreign holiday and opening a savings account. Both care plan files also included detailed risk assessments covering road safety, sexuality, mobility, cooking and travelling independently. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 9 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) 12, 13, 15, 16 and 17. Service users are supported by staff to take part in a wide range of appropriate leisure activities. Staff also support service users to maintain contact with family and friends. EVIDENCE: The two care plans reviewed during this inspection each included a full programme of activities during the daytime, evenings and at weekends. Staff demonstrated a clear understanding of each person’s activity programme, their likes, dislikes and routines. Staff have developed good links with local day services and other education and leisure services. Each person living in the home has an annual holiday, supported by staff. This is organised by key workers who support the service user to choose where they would like to go. Two service users have said that they would like to go to Spain this year and staff are arranging this. One person will have a series of day trips, as they do not like staying away from the home overnight. The fourth person said that they would like to have a foreign holiday, but this is not possible as their savings are insufficient to pay for the holiday and the staff costs involved. This situation is unlikely to improve in future, as the service user’s benefits do not enable them to save the money needed to pay for a holiday. Yarrow should PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 10 negotiate with the local authority to ensure that the weekly fee paid for placements in the home includes the cost of a holiday each year. Two service users returned confidential questionnaires. home provided appropriate activities. Both said that the Contact details for relatives and other significant people are included in the care plan and there are clear routines for maintaining contact. One person spends time each weekend with relatives and the second person visits their mother each week, supported by staff. Staff also ensured that this person’s mother and other relatives came to a birthday party. Six relatives returned confidential questionnaires. Their comments included: ‘Staff are very dedicated and provide a high standard of care (my relative) seems very happy there’. ‘I am 100 happy with the care given’. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 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 standard(s) 18, 19 and 20. Service users’ health and social care needs are well met in the home. The staff team has established good links with local specialist services. EVIDENCE: The last inspection report included a requirement that the management of service users’ prescribed medication must be improved. During this visit, the Inspector checked the Medication Administration Record (MAR) sheets and found that good standards of recording and management are now being consistently achieved. The two care plans reviewed included good information about each person’s health care needs and how these are met in the home. The home has good links with local mainstream and specialist health and social care services for people with a learning disability. All services users are registered with local GPs and a detailed record is kept on each file of any medical appointments and the outcomes. Appropriate referrals are also made to specialist clinicians, including psychologists and speech and language therapists. Three health and social care professionals returned confidential questionnaires sent out as part of this inspection. One person said that they had had little contact with the home in the last year. The two other people said that staff in the home have a clear understanding of service users’ care needs and care plans are in place and are regularly reviewed. Both people said that they were satisfied with the overall standards of care provided at Percy Road. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 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 standard(s) 22 and 23. People living at Percy Road have access to a clear and accessible complaints procedure. Service users’ safety is promoted by staff who are aware of local adult protection procedures. EVIDENCE: The home has a clear complaints policy that has been produced in an accessible format for service users. There have been no formal complaints since the last inspection. One service user told the Inspector that when people living in the home argued, ‘staff always sort it out’. Staff told the Inspector that differences of opinion would be dealt with by staff on duty and recorded in service users’ daily log books. All staff were aware of the home’s complaints procedure and knew how to support service users to make a complaint. Six relatives returned confidential questionnaires. Although all six people said that they had never needed to make a complaint, three people said that they were unaware of the home’s procedures. It is a recommendation of this report that the Manager ensures all relatives are aware of the home’s procedures. The Inspector checked the finances records of two people living in the home. The records are well managed, all transactions are recorded and receipts are always obtained. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 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 standard(s) 24, 25, 27, 28 and 30. The home provides very good standards of private and communal spaces for service users. There is a need to review the standards of fire safety in the home. EVIDENCE: 97 Percy Road is an end-terrace property that is indistinguishable from other houses. It is close to local shops and bus routes. The accommodation provided is not suitable for people with a physical disability or mobility problems, if the person cannot manage stairs. Accommodation is provided on 3 floors. Each service user has a single bedroom and the lounge, kitchen/dining room, bathroom, shower room toilets, laundry room and a small garden/patio are shared. Since the last inspection the home has been completely redecorated and now provides very good standards of homely accommodation. During this visit the Inspector noted that a number of fire doors in the home are ill-fitting and have large gaps around the frames. The Manager must arrange for a Fire Officer to visit the home and assess the fire safety standards. Doors to the kitchen and laundry room must also be approved by the Fire Officer. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 14 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) 32, 34 and 35. Service users benefit from a home that is well staffed and managed. EVIDENCE: The home has a stable staff team and there has been only one change since the last inspection. There is currently one vacancy and the Manager confirmed that interviews are planned shortly. The Manager is experienced and staff spoke positively about the leadership she provides. During this inspection the Manager was on duty with three care staff. A fourth care staff also arrived to cover the afternoon shift. The Inspector felt this level of staffing is appropriate and enables staff to support service users at home and in the local community. During this inspection the staff team worked well together to ensure that important information about service users was known to all staff. All four people living in the home were also supported to spend time in the local community during the day. The Manager told the Inspector that two staff are due to start their NVQ Level 3 training and a third person is due to finish their Level 2 qualification. There is a need for Yarrow to ensure that staff have access to NVQ training to ensure that the target of 50 qualified staff is achieved this year. Criminal Record Bureau Enhanced Disclosures have been obtained for all staff and copies are kept in the home. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 15 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, 39, 41 and 42. The home is well managed, all policies and procedures have been developed and standards of record keeping are good. EVIDENCE: The home’s Manager has completed the NVQ Assessor’s Award, but she does not have the Registered Manager’s Award. Yarrow must ensure that the home’s Manager undertakes the required qualification training. All of the policies and procedures required to meet these Standards have been developed by Yarrow and copies are available in the home for staff reference. The Inspector checked two service users’ care plans, finance and medication records. The Inspector felt that standards of recording in the home are good and standards of care planning are excellent. The last inspection report included a requirement to implement an independent quality assurance system. Although some good work has been done in the home to record service users’ views, this requirement is repeated. PERCY ROAD G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 16 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 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 2 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 PERCY ROAD Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 2 x 3 3 x G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 17 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 YA24 Regulation 23 Requirement The Manager must arrange for a Fire Officer to visit the home and assess the fire safety standards. Doors to the kitchen and laundry room must also be approved by the Fire Officer. Yarrow must ensure that staff have access to NVQ training to ensure that the target of 50 qualified staff is achieved this year. Yarrow must ensure that the home’s Manager undertakes the required qualification training. An independent quality assurance system must be implemented. Repeat requirement - time scale of 31/03/05 not met. Timescale for action 30/06/05 2. YA35 18 31/12/05 3. 4. YA37 YA39 9 24 31/12/05 30/09/05 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 YA14 Good Practice Recommendations Yarrow should negotiate with the local authority to ensure that the weekly fee paid for placements in the home G60-G09 S19141 PERCY ROAD AIV219103 170505 STAGE 4.doc Version 1.30 Page 18 PERCY ROAD 2. YA23 includes the cost of a holiday each year. The Manager should ensure that all relatives are aware of the home’s complaints procedures. 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