Inspection on 18/10/05 for Percy Road, 97

This inspection was carried out on 18th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Percy Road, 97 12/02/09

Percy Road, 97 09/04/08

Percy Road, 97 29/06/07

Percy Road, 97 17/05/05

Percy Road, 97 15/12/04

Percy Road, 97 18/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

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 Percy Road, 97 Percy Road 97 Percy Road Shepherds Bush London W12 9QH Lead Inspector Tony Lawrence Unannounced Inspection 18th October 2005 09:30 Percy Road, 97 DS0000019141.V258865.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 Percy Road, 97 DS0000019141.V258865.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. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Percy Road, 97 Address Percy Road 97 Percy Road Shepherds Bush London W12 9QH 020 8743 0044 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 Miss Sonia Ann Gray Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/05/05 Brief Description of the Service: 97 Percy Road is a registered care home that provides accommodation and personal care for people with a learning disability. At the time of this visit, 2 men and 2 women were living in the home. Threshold Tennant Trust Housing Association owns the property. The care is provided by Yarrow Housing, a voluntary organisation. The home is located in a residential area of Shepherd’s Bush, close to shops and public transport. There is a lounge, kitchen/dining room, four single bedrooms, bathroom / WC and shower room / WC. Percy Road, 97 DS0000019141.V258865.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 Tuesday 18th October 2005 from 08:45-12:15. The Inspector spoke with two people living in the home and staff on duty, checked care records and saw all communal parts of the home. One of the four requirements made at the last inspection has been met. It was not possible to check two requirements and these are repeated. One requirement no longer applies as it concerned the manager who is currently on maternity leave. The home provides a good standard of accommodation but there is a need to review staffing levels and the management of service users’ finances. 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, 97 DS0000019141.V258865.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: The key Standards were all met at the last inspection in May 2005. No new service users have moved into the home since the last inspection. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 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 the following standard(s): 8 and 10. People living in the home are involved in making choices about the daily lives. EVIDENCE: The key Standards were all met at the last inspection in May 2005. During this visit the Inspector saw staff working well together as a team to make sure service users’ care needs were met. As she had a GP appointment, the Deputy Manager had arranged for a member of staff to come in early to provide cover. Each person living in the home has a weekly programme of activities. These are well known to staff and the team worked well together to make sure that each person was supported to take part in planned activities. Confidential information about service users is securely stored in lockable cupboards in the home’s office. The Inspector did see one service user go into the office and look in the desk drawers when staff were in other parts of the home. Staff should ensure that the door is locked when they are away from the office. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 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 the following standard(s): 14. Service users are supported to take part in a range of leisure activities, but this is restricted at weekends. EVIDENCE: The key Standards were all met at the last inspection in May 2005. The Inspector saw that all four residents have opportunities to take part in a range of leisure activities, in the home and the wider community. Individuals are supported to personalise their rooms and are able to have their own TV, music system, games consoles etc. The main lounge also has a TV with satellite channels and a computer that residents can use. Log books show that people are supported to use local shops, pubs, cafes and cinemas and discos. Each person also has allocated 1:1 time each week when they can choose an activity. During this visit, one person travelled independently to a local dance class and one person was collected by transport from the local authority day service. Two people remained in the home for most of the inspection. One person did Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 10 later go shopping with staff and both people were due to go to an art class in the afternoon. There are issues about levels of staff support provided at weekends and the opportunities service users have to take part in activities. These are discussed later in this report. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. The health care needs of service users are well met in the home. EVIDENCE: The key Standards were all met at the last inspection in May 2005. During this visit the Inspector checked the medication records for all four residents. The records were up to date and well maintained by staff. Secure storage is provided for medication in the home’s office. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. The arrangements for the management of service users’ finances are inadequate and must be reviewed. EVIDENCE: During this visit the Inspector checked the finance records for all four service users. In all four cases the Inspector feels that there is evidence of service users’ personal money being used inappropriately. This mostly happens when service users are on holiday, supported by staff. The records show that service users’ money is used to pay for staff fares and entrance fees to theme parks, museums and bus tours. In one case this amounted to £132. Another service user also paid for taxis for two staff to travel from Percy Road to their homes, after they supported her on holiday. Another service user paid £640 for a short break in Cardiff, when she shared a room with the two staff supporting her. This is not appropriate and should not have been allowed by Yarrow managers. This person also paid for staff supporting her when she went bowling. The Inspector is concerned not only that the money was used in this way, but that the inappropriate use of money was not identified by the home’s managers. Managers from Yarrow are expected to carry out monthly monitoring visits and these visits could be used to carry out an audit of service users’ finances. There is no evidence in the home that these visits are taking place. The use of service users’ money in this way is inappropriate and an immediate review of the management of finances is needed. The results of the review must be sent to the Commission. If money is found to have been misused, this must be refunded. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 and 30. Service users benefit from homely and comfortable accommodation. EVIDENCE: All key Standards were met at the last inspection in May 2005. During this visit, the Inspector saw all communal parts of the home and one service user’s bedroom. All parts of the home are well furnished and the service user’s bedroom was well personalised. A part-time cleaner is employed and all parts of the home were clean and tidy during this visit. The last inspection report included a requirement that the manager must arrange a visit by the Fire Officer to assess fire safety standards. In particular, confirmation is needed that the kitchen and laundry rooms doors meet fire safety requirements. Although the home’s visitors book showed that an officer from the London Fire and Emergency Planning Authority visited the home in June 2005, no report of this visit was available. Evidence is needed to show that fire safety standards in the home are adequate and the requirement made at the last inspection is repeated. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 35. Service users are supported by committed and enthusiastic staff but there are insufficient staff at weekends to support people living in the home. EVIDENCE: When the Inspector arrived at 08:45 the Deputy Manager was on duty alone. She had slept in the night before and started her morning shift at 07:00. A second member of staff arrived at 09:00. As the Deputy Manager had a GP appointment, she had arranged for another member of staff to start a shift early, at 12:00. This person had agreed to come in early, but this still left one member of staff alone in the home with two service users for an hour. While staff worked well together to ensure service users were supported, single staffing restricts opportunities for people living in the home. The Inspector discussed this with staff and checked the home’s rota. The home currently has one vacancy for a Residential Support Worker and a bank worker who has worked in the home for some months covers a second vacancy. At weekends there are significant periods of the waking day when only one person is on duty in the home with four service users. Typically this amounts to six or seven hours every Saturday and Sunday. The Inspector checked the log books of all four service users to see the activities they had been offered for three weekends during October. Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 15 On 1st and 2nd October, one service user went shopping once with staff. A second person went shopping and visited her mother with staff support on 1st but did not go out at all on 2nd. A third person went shopping with staff on 1st and went out with relatives on 2nd. There was no evidence that the fourth person left the home during the weekend. On 8th and 9th October, The morning log for one person was not completed on 8th but they went shopping with staff in the afternoon and went to the pub with other service users and staff on 9th. The morning log for a second person was also not completed on 8th, but this person did go out with relatives on 9th. The morning log was not completed for the thirds person on 8th but they did go to the shop and pub with other service users and staff on 9th. The log shows that the fourth service user only went to the pub with staff and other service users on 9th. There was no evidence that two service users left the home at all during the weekend of 15th and 16th October. One person went shopping on 15th and another service user went out with relatives on 15th and 16th. This level of staffing is inadequate and does not enable service users to take part in activities they choose at weekends. During this visit, the Inspector saw one service user ask staff on a number of occasions when they would be going shopping. This was not possible until later in the day due to staff sickness and the need to provide cover in the home. Staff also told the Inspector that this person relies on visits from relatives at weekends, as they cannot always support service users due to the minimal staffing levels. The home’s rota also shows that one vacant post in the home is not covered by bank or agency staff. This limits the manager’s ability to provide two staff on duty for each shift at weekends. Yarrow must urgently review the staffing levels in the home, especially at weekends to ensure service users have appropriate support at all times. Staff told the Inspector that the deputy manager is completing her NVQ Level 3 training. One Residential Support Worker (RSW) has completed NVQ Level 2. Another RSW is currently doing NVQ Level 3 and a third RSW is due to start Level 2 in January 2006. While the home will not meet the target for 50 qualified staff by 31st December 2005, the Inspector was satisfied that arrangements are in place to ensure this Standard is achieved during 2006. Percy Road, 97 DS0000019141.V258865.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, 39, 41 and 43. Standards of record keeping are good. There is a need to improve the monitoring of the home and the new manager must apply for registration with the Commission. EVIDENCE: Since the last inspection in May 2005, the registered manager has left on maternity leave. The manager from another Yarrow home has been seconded to Percy Road for a period of up to one year. The new manager must contact the Commission’s Central Registration Team to apply for registration. Yarrow must also ensure that monthly monitoring visits are made to the home. Copies of reports written after each visit must be sent to the home and the Commission for information. During this visit the Inspector checked service users’ log books, medication and finance records. Standards pf record keeping are good, but staff must ensure that the log books for each service user are completed at the end of each shift. Percy Road, 97 DS0000019141.V258865.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 X X X X Standard No 22 23 Score X 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 1 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Percy Road, 97 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X 2 X 2 DS0000019141.V258865.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 4 Standard YA23 YA23 YA23 YA24 Regulation 13 13 13 23 Requirement The use of service users’ personal money must be reviewed immediately. The results of the review of service users’ finances must be sent to the Commission. If service users’ money has been misused, this must be refunded. The Fire Officer must confirm that fire safety standards in the home are adequate. (Original timescale of 30/06/05 not met). Yarrow must urgently review the staffing levels in the home, especially at weekends, to ensure service users have appropriate support at all times. The new manager must contact the Commission’s Central Registration Team to apply for registration. Staff must ensure that the log books for each service user are completed at the end of each shift. Yarrow must ensure that monthly monitoring visits are made to the home. Reports written after each visit must be DS0000019141.V258865.R01.S.doc Timescale for action 30/11/05 30/11/05 30/11/05 30/11/05 5 YA33 18 30/11/05 6 YA37 9 30/11/05 7 YA41 17 30/11/05 8 YA43 26 30/11/05 Percy Road, 97 Version 5.0 Page 19 sent to the home and the Commission. 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 YA10 Good Practice Recommendations Staff should ensure that the door is locked when they are away from the office. Percy Road, 97 DS0000019141.V258865.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. Extracts may not be used or reproduced without the express permission of CSCI Percy Road, 97 DS0000019141.V258865.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!