Inspection on 29/06/07 for Percy Road, 97

This inspection was carried out on 29th June 2007.

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 no outstanding requirements from the previous inspection report, but made 1 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 18/10/05

Percy Road, 97 17/05/05

Percy Road, 97 15/12/04

Percy Road, 97 18/05/04

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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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 97 Percy Road Shepherds Bush London W12 9QH Lead Inspector Wynne Price-Rees Key Unannounced Inspection 29th June 2007 10:30 Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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.V344218.R01.S.doc Version 5.2 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.V344218.R01.S.doc Version 5.2 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) info@yarrowhousing.org.uk Yarrow Housing Miss Sonia Ann Gray Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd May 2006 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.V344218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five hours on one day. All four residents files were case tracked, records checked, staff and residents spoken with and a premises tour took place. 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 Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 6 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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 Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a written pre-admission assessment policy and procedure in place that staff understand and would follow if a new resident were to move in. There have been no new admissions since the last key inspection and the last resident arrived in 2004. Historic assessment information was on file for the residents. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All four residents’ files were case tracked and the support plans were person centred. They identified needs, objectives, person responsible, outcomes, timescales and reviews. The plans were underpinned by up to date risk assessments that were mostly reviewed on 1st May 2007 and enabled residents’ to make progress towards the goals set. The risk assessments are reviewed a minimum six monthly or as and when required. They cover activities inside and outside the home. Residents also have social histories that they have contributed to in compilation. The support plans are signed off by the residents’. Up to date health assessments were also available. Each resident has an individual daily log that identifies progress made towards goals set. There were also signed contract agreements on file. Regular residents’ meetings take place that are minuted in written and pictorial form to make them easier for residents to understand. They fully participate in Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 10 decision-making and have access to an advocacy service if required. This was further evidenced by the home’s daily routine that is fitted to the needs and wishes of the clients rather than the other way around. Clients were observed coming and going and carrying out activities as they pleased. Quality questionnaires completed by residents with staff support were on file for 2006. This year’s questionnaires have not yet been issued. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents attended an employment day at the organisation’s central offices designed to identify anything residents’ would like to do. Various occupations were identified such as gardening, office work and stacking shelves in a supermarket. One resident stated that they did not wish to work. One resident is participating in an individual learners plan at Hammersmith and West London College where they participate in “The learning journey” and gym sessions. Another resident attends maintenance classes at the Gate as they enjoy fixing and making things. They go each day. Someone else attends sessions in cookery, banking, news group where they pick and discuss topic and plant maintenance. This resident bundles up flowers as part of the plant maintenance sessions that are then for sale. Unfortunately their mum passed away earlier this year and they made the wreath for the funeral. Everyone also helps with the garden at home. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 12 Good use is made of local facilities such as shops and restaurants. Relatives and friends also frequently visit. On the inspection day, one resident was picked up by their brother to attend the funeral of a relative. A resident went on holiday to Disneyland Paris last year and arrangements have been made to go later on this year. Other activities include music, art classes and literacy in action. Residents are also supported to participate in tasks around the home such as laundry and cleaning their rooms as part of life skill development. Each resident has a timetable that includes a one to one day where they choose an activity that generally includes a meal out. The residents’ participate in menu planning and some enjoy food shopping. The main meal of the day is in the evening when everyone is at home and is used as an opportunity to socialise. They choose a takeaway meal each Friday evening. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents are registered with GPs at various surgeries and they are supported to keep appointments that are recorded. They have full access to community based health care services. The support plans contained up to date health action plans and annual health checks take place. One resident went to a dental appointment during the inspection. Personal care is provided as and when required and this generally takes the form of prompting to maintain personal hygiene. One resident came to take their medication in the office. Unfortunately this was dropped and replaced with an entry made in the medication administration sheets so the medication tally would balance. All the MARR sheets were checked and there were found to be gaps with no symbol or signature entry. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ have been made aware of the complaints procedure although prefer to talk directly with whoever is on duty at the time. A resident did have an advocate although the advocate did not feel they were needed, as the resident was more than capable of expressing themselves and their views. There were no complaints recorded since the last key inspection. The staff have received training in abuse identification and are fully aware of the procedure to follow if encountered. They have also been trained in dealing with challenging behaviour except one staff member who is due to attend. Care practices observed demonstrated that residents are listened to and their views taken into account. There was one POVA referral in October 2006 that has now been closed. All staff have been CRB cleared and the home checks with the agency that they have been cleared if any agency staff are used. The residents all have their own bank or building society accounts and no one at the home is an appointee. They have individual tins were valuables and money are kept on their behalf. All transactions are recorded. Two residents pay their rent monthly. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is fit for its stated purpose and premises showed it was safe, comfortable, clean, tidy, well decorated and hygienic. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently two vacancies for residential support workers that are covered by bank staff, internally or agency staff. These vacancies are being advertised. The rota showed that there are sufficient staff on duty to meet residents’ needs. Currently the staff team exceeds the required fifty percent NVQ level 2 level. A comprehensive rolling training programme is provided that focuses on the client group and staff also have access to training provided by Hammersmith and Fulham Council. Training needs are identified during supervision sessions and annual appraisals. Full induction is also provided. There is a comprehensive written recruitment procedure that is based on equal opportunities and includes CRB and POVA disclosures. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Care Manager has worked for the organisation for eleven years in various capacities, has managed the home for five years, is an NVQ assessor and currently undertaking an NVQ level 4 management qualification. There is a comprehensive quality assurance system with performance indicators and trigger levels that is reviewed annually and regularly monitored. The development plan is tailored to the individual project and then incorporated within the organizational business plan. Residents and relatives feedback is received through questionnaires and have your say meetings. The requirements of standard forty-two were met. Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 18 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 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 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 19 NO 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 YA20 Regulation 13 (2) Requirement All medication administration sheets must be accurately filled in with appropriate symbol or signature. Timescale for action 14/07/07 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 Percy Road, 97 DS0000019141.V344218.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V344218.R01.S.doc Version 5.2 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. 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