Inspection on 09/04/08 for Percy Road, 97

This inspection was carried out on 9th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 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 29/06/07

Percy Road, 97 18/10/05

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 Jacqueline Derbyshire Key Unannounced Inspection 9th April 2008 08:45 Percy Road, 97 DS0000019141.V361727.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.V361727.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.V361727.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.V361727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. learning disability - Code LD The maximum number of service users who can be accommodated is: 4 29th June 2007 Date of last inspection 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. There are four people living at Percy Road, 2 men and 2 women. Metropolitan Housing Trust owns the property. Yarrow Housing, a voluntary organisation, provides the care. 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, and a small garden at the back of the house. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Wednesday 9th April 2008; we spent 4 hours visiting the home. We spent time talking with residents, staff and the manager, checking care records and touring the building. We also reviewed the care of two people living in the home in more detail. The home provides adequate standards of accommodation, is well staffed to meet the care needs of residents and standards of record keeping are good. People living in the home are supported to take part is a varied programme of activities during the day, evenings and at weekends. The London Fire and Emergency Planning Authority (LFEPA) made a visit to the home 09/05/08 to look at the homes fire risk assessment and look at the environment to make sure it is safe. Recommendations were put in place that have to be met by the organisation to ensure the safety of residents and staff. One requirement made at the last inspection has been met; there are four new requirements. We received six resident and family surveys’ their comments are included in the report. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly fee for living at Percy Road is £963.86. What the service does well: All residents are now taking part in their Person Centred Planning (PCP), we saw plans with photographs, drawings and up to date relevant information on the aims and aspirations of the individuals. All care plans and risk assessments records were up to date, with review records showing relevant changes that have occurred in residents’ lives. All residents are up to date with their health checks. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Percy Road, 97 DS0000019141.V361727.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.V361727.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): Standard 1 and 2.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets objectives and philosophy of the service supported by a service user’s guide. EVIDENCE: Comments made by people who use the service. ‘Percy Road has a good family atmosphere’ ‘My relative is very happy since they moved into Percy Road’. We looked at the Statement of Purpose and Service User Guide, both documents have the up to date information for prospective people considering using the service. There are no vacancies at present at Percy Road. The AQQA gives clear information on what the service does well and how all of the residents’ are promoted to voice their opinions on the care they receive. The home has not had any new residents for three years. We looked at the information on two residents files that had been living at the home for a few years, both had a full care needs assessment in place that had been reviewed regularly to meet the changing needs of the individuals. Percy Road, 97 DS0000019141.V361727.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): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are person centred and are agreed with the individual. Plans are written in plain language, are easy to understand and look at all areas of the individual’s life. They include reference to equality and diversity and address any needs identified in a person centred way. EVIDENCE: We looked at two residents files both had a very comprehensive care plan in place. The care plans had a lot of information linking into the daily routine of the individuals. There was a communication passport ‘All about Me’ in the both persons files’ that were very informative showing the individuals likes, dislikes their family and what activities they enjoyed doing. Person Centred Planning meetings and reviews are all up to date we saw (PCP’s) that are in pictorial formats with photographs of activities and the likes and dislikes of an individual, PCP’s are used as an ongoing record. We were told by one resident that were attending a review that week and looking forward to it. In discussion with three of the residents we were told they liked the home and the staff were really nice. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 10 The two files checked had risk assessment records in place that linked into the care plan for any risk areas and how the staff were eliminating or minimising the risk. The manager discussed the risk assessments stating that they are a working document that are reviewed regularly and changed accordingly. Percy Road, 97 DS0000019141.V361727.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): Standards 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are engaged in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. They have been fully involved in the planning of their lifestyle and quality of life. EVIDENCE: We looked at two residents files and care needs assessments. Both files contained a lot of information regarding information about the resident’s likes, dislikes, hobbies and leisure interests. We were told by the manager that one resident had two jobs that they very much enjoyed. We looked at daily records for the people staying at the home and there was information written daily about what activities an individual had done including shopping, eating out, and going for walks and attending any community centres. On the day of this inspection three of the residents went out to different activities in the community including art and dance classes. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 12 Daily care notes completed by staff show that residents are supported to take part in activities in the home and the wider community. Regular use is made of local cafes, shops and the cinema, as well as local parks. Details of resident’s family, friends and other important people are in all residents’ files. Contact details of all significant people are clearly recorded and daily care notes show that friends and relatives visit residents especially on special occasions such as birthdays. We were told that the home does a big weekly shopping for food but shop regularly for the food requested by the residents. A two weekly menu is planned by the four residents and staff, the menu for those weeks had a varied selection and was looked at by staff for the nutritional needs of all residents including a lot of fresh fruit and vegetables. The menus are in pictorial formats and on display in the kitchen. In discussion with three of the residents we were told that they liked the food provided. The Annual Quality Assurance Assessment (AQQA) form completed does go into great detail about the different diverse needs of people using the service and how they try to provide a varied menu. Percy Road, 97 DS0000019141.V361727.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): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. The delivery of personal care is individual and is flexible, consistent, reliable and person centred. EVIDENCE: We saw information on both files looked at including referrals to health and social care professionals. We saw reports from social workers, occupational therapists, psychologists and speech and language therapists. The reports each contained useful information and guidance for staff. In discussion with the manager and staff on duty at this site visit, it was clear that different levels of support are required for each resident. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 14 All of the people who live at Percy Road are registered with their own GP and records in place showed that the residents had regular healthcare checks. In discussion with the manager we were told that all residents are up to date with optical, dental and all other health checks. We looked at the medication storage and (MAR) sheet records kept at the home that were well recorded and accurate. We were told by the manager that all staff have had medication training and are fully aware of the medication policy and procedure. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some staff had training around safeguarding adults but others have a limited understanding in this important area. This leads to inconsistent knowledge and practice within the service. EVIDENCE: We looked at the complaints file that had no complaints recorded in the last 12 months. The manager confirmed that residents all have the complaints procedure in their files in a format that they can understand. Yarrow has regular meetings called ‘Have your Say’ where residents can attend to discuss any issues they may have or raise any concerns. Records are also taken at the two weekly house meetings where all residents are asked if they have any issues they would like to discuss. There have been three safeguarding incidents at the home in the last 12 months, the relevant professionals were not notified and staff did not follow the correct procedure. In discussion with the manager we were told that safeguarding procedures will be revisited for all staff and training provided to make sure all staff know how to inform the relevant people. We looked at the finances of the two people staying at the home, the records were correct with receipts in place for any financial transactions made with the resident or on their behalf. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,26 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is in need of a programme to improve the decoration, fixtures and fittings. Occasionally there is a slippage of timescales and maintenance tends be reactive rather than proactive. EVIDENCE: We had a full tour of the home and all areas were seen. All of the communal areas in the home require decorating. Furniture was seen in a resident’s bedroom that needs repairing or replacing. One resident escorted the inspector into the kitchen to point out the work surface that had been damaged and kitchen cupboard doors that need repairing or replacing. There has been a visit by the London Fire and Emergency Planning Authority (LFEPA) and recommendations were made, certain doors need to be changed to meet fire regulations and ensure the safety of all people living and working at Percy Road. The home was seen to be clean and tidy in all areas. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. EVIDENCE: On the day of the Inspection there were 3 staff on duty including the manager. We looked at rotas and sufficient staff was scheduled to be on duty on all shifts. The organisation has been successful in the last recruitment drive and two staff has been employed. We were told by the manager that there is a vacancy that is covered by bank staff. The Manager sent the Inspector information showing that all staff including agency staff has a full Criminal Records Bureau (CRB) Disclosure. We were also sent the training completed by all staff; there is the issue of all staff revisiting safeguarding training. All recruitment is completed by the Human Resources team at Yarrow with people who use the service being involved with the interviews. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 18 The manager is registered for the NVQ level 4 qualification, the manager keeps a training and development schedule for herself and the Annual Quality Assurance Assessment (AQQA) states that the manager undertakes regular training courses to update her knowledge. The manager sent a list of all training to date that all staff have completed including mandatory training, with information on qualifications each person employed has. We were told by the manager that training is available for all staff and she is making sure that all people working at Percy Road have a development plan in place. New staff recently employed will be completing the organisations induction training. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All sections of the AQQA were completed and the information gives a reasonable picture of the current situation within the service. EVIDENCE: The Manager has worked with Yarrow for 12 years and is very experienced having been the manager at Percy Road for six years. The Manager writes in the (AQQA) that Percy Road is a home that can offer consistent care with a good management structure in place. All of the records looked at had dates and signatures in place, and were stored in lockable cabinets in the office. Yarrow has a comprehensive quality assurance system with performance indicators and trigger levels that is reviewed annually and regularly monitored by person in control monthly visits and self audits. We saw completed quality questionnaires that were filled in by residents with family or external professional assistance. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 20 We were given the dates for all Health and safety checks in the (AQQA) that show they are all up to date. The fire alarm, water temperatures and fridge freezer temperatures were looked at were well recorded with no issues. There is an issue around works being completed by the organisation from recommendations set by the London Fire and Emergency Planning Authority (LFEPA); this work must be completed by the deadline to ensure the safety of all residents and staff. The organisation must put in place a fire risk assessment. There are fire evacuation risk assessments in place for all four residents. Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 2 ENVIRONMENT Standard No Score 24 2 25 x 26 2 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 3 x 3 x 3 x x 2 x Percy Road, 97 DS0000019141.V361727.R01.S.doc Version 5.2 Page 22 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 YA23 Regulation 37 Requirement The manager must revisit the safeguarding procedures in the home to make sure all staff is fully aware of the procedures to follow when an incident occurs. The organisation must decorate all areas of the home to make the home comfortable for all of the people living there. The organisation must repair or replace all broken furniture and fixtures in the home to make the home comfortable for all of the people living there. The organisation must meet the fire safety recommendations set by the LFEPA. Timescale for action 09/05/08 2 YA24 23 09/09/08 3 YA26 23 09/06/08 4 YA42 YA24 23 09/05/08 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.V361727.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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