Inspection on 18/07/05 for Randolph Avenue, 248

This inspection was carried out on 18th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Randolph Avenue, 248 29/09/09

Randolph Avenue, 248 06/11/07

Randolph Avenue, 248 18/12/06

Randolph Avenue, 248 06/02/06

Randolph Avenue, 248 11/01/05

Randolph Avenue, 248 26/07/04

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

CARE HOME ADULTS 18-65 RANDOLPH AVENUE (248) 248 Randolph Avenue LONDON W9 1PF Lead Inspector Ffion Simmons Unannounced 18 July 2005 10.15 am 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. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Randolph Avenue (248) Address 248 Randolph Avenue, London W9 1PF 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 7625 8975 020 7624 8948 Mental After Care Association Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: n/a Date of last inspection 11 January 2005 Brief Description of the Service: Randolph Avenue is a home for up to 12 service users with a mental health disorder. The home is managed by Maca (Mental After Care Association) and Octavia Housing Association is responsible for maintenance. The home is situated in Maida Vale with good transport links and access to community services. Each service user has their own single bedroom and have access to communal areas. The home has a lounge equipped with TV, video and hi-fi. There is a kitchen on the lower ground floor, which opens into a spacious garden. There is also a quiet room on the lower ground floor equipped with a computer printer and TV. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on the 18th July 2005 between the hours of 10.15 and 16.00. The inspector spent time talking to 3 service users, the staff team, the Manager and a range of paperwork was examined. A tour of the communal areas was also undertaken. Pre-inspection information was received and comment cards were also received from service users. What the service does well: What has improved since the last inspection? What they could do better: Six of the eight requirements set at this inspection are mainly focused on issues relating to the environment and health and safety. There is an urgent need for the floor coverings in all bathrooms and toilets to be replaced. The floor covering in the kitchen situated on the lower ground floor is looking tired and is in need of replacing. Since the last inspection, the cause of the water damage to the ground floor hallway ceiling has been identified and is now in need of re-decorating. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 6 Staff must ensure that water temperatures are regularly tested to ensure safe delivery of water and the home’s gas supply requires testing also. There is a need also for staff to become familiar with the content of the local multi-agency policy for the protection of vulnerable adults and for the Manager to submit an application to register with the CSCI as the Registered Manager of the home. 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. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 4 & 5 The home’s information pack is comprehensive and clearly reflects the projects aims and objectives. This enables service users to make an informed choice about living at the home and the level of personal commitment that is required. The referral information is excellent with a good level of information being available about the needs of the service users prior to them moving in to ensure that the placement is appropriate. Service users are aware of the terms and conditions between themselves and the home. EVIDENCE: There is an information pack available, which contains comprehensive information on the services provided at the home. The statement of purpose and service user’s guide has been updated to clearly reflect that the project aims to provide a structured and rehabilitative accommodation for a maximum period of two years. Within the last month, there have been two new service users admitted to the home. The inspector looked at their personal files. The referral documentation was very clear and correspondence with referring agencies and other professionals was clearly recorded. There was a good level of information available on file including needs assessments and risk assessments. The staff at Randolph Avenue also conducted a formal assessment of service users’ needs. A care plan was also in place based on their individual needs. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 9 Service users spoken with during the inspection confirmed that they visited the house prior to moving in. On the morning of the inspection, a prospective service user visited the home to look around. The tour of the building was facilitated by a senior support worker on duty. All personal files checked had a signed contract of terms and conditions between the home and the service user. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9, The quality of the paperwork is very good with care plans being up-to-date and regularly reviewed with the input of the service user. Risk assessments and risk management plans are in place and are thorough. Daily notes are very clear and give a good insight into the life of the service users. EVIDENCE: The personal files of three service users were checked during the inspection. Each of the plans were up to date and are reviewed regularly. One of the service users spoken with confirmed that they were aware of the content of their care plan and that they have signed it. They also listed some of the topics set out in their care plan which include mental health and medication, general health, budgeting and finances, household activities, day programme and personal activities and personal hygiene. Service users were able to name their key worker and confirmed that weekly key working sessions take place. One of the service users said that service users have been consulted with, and prefer to have their house meetings on Monday evenings. Here service users have the opportunity to contribute to any issues including maintenance and activities. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 11 Risk assessments and risk management plans were available on all three files checked and were detailed. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 12 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) 11,12,13,15 & 17 Service users have structured activity programmes aimed at developing their independent living skills. Weekly key working sessions are held where staff offer good support to service users to access employment, education and social opportunities. Routines are flexible, providing service users with the freedom to make their own decisions about their lives and their daily activities. EVIDENCE: The aim of the project is to provide service users with a structured and rehabilitative programme for developing their independence in order to move on to semi-independent or independent living as appropriate. Service users are required to take part in general household chores such as cleaning, cooking, attending to their laundry and food shopping. Their allocated days for attending to the chores are outlined in their care plans. The service users spoken with were very clear about their programmes and one of the service users expressed that they really enjoyed cooking and attend a cooking session at the day centre. There is a menu on the notice board outlining what meal will be provided and who will be responsible for cooking it. Service users take it in turns to cook the evening meal for the group. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 13 Two of the service users spoken with told the inspector that they have enrolled on a six-week English course at Westminster College. Later, one hopes to study graphics. Another service user said that they have enrolled on a Media and Photography course at Westminster College and also plan to attend a fourweek IT course. Staff had supported them to access the courses and enrol. One of the service users also confirmed that their key worker assisted with their travel plans and accessing public transport. Service users are supported to take part in the local community and to maintain links with their families. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 14 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) 19 & 20 The key working system offers continuity of care to service users. The medication systems in use in the home promote safe progression to selfmedication within a risk-assessed framework. EVIDENCE: Service users’ personal care needs are outlined in service users’ care plans. Times for getting up and going to bed are flexible depending on service users’ wishes. Medication is dispensed by staff into a dosset box on a weekly basis and is securely stored in a lockable cupboard. A five stage self-medication programme is in place for those service users who have been assessed as able to self-administer. The staged self-medication programme aims to gradually promote service user’s independence. Daily medication checks are undertaken as part of the handover, and weekly audits are undertaken on the medication totals. The medication administration records were well completed. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The complaints policy is well publicised and service users feel comfortable talking to staff when they are unhappy about aspects of their care. Policies are available for protecting vulnerable adults from abuse. Staff need to ensure that they are familiar with the multi-agency policy for the protection of vulnerable adults. EVIDENCE: According to the information supplied within the pre-inspection documentation, the home has received one complaint within the last twelve months. The home has a complaints policy, which was visible on the notice board at the time of the inspection. Service users spoken with said that they would speak with staff if they would be dissatisfied with any aspects of their care. The home has a policy for responding to suspicions or actual abuse of service users. Since the last inspection, the home has obtained a copy of the multiagency policy and procedure for the protection of vulnerable adults. Staff were not aware of the content of this policy and it is a requirement that all staff become familiar with the content of this policy. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27, & 28 The home is suitable for it purpose. Some aspects of the environment falls below the minimum standard and must be immediately improved to ensure that service users are accommodated in a safe, comfortable and hygienic environment. EVIDENCE: Randolph Avenue is a large, terraced, five-storey Victorian building situated close to the local amenities of Maida Vale. The inspector viewed all the communal areas during the inspection. There is a lounge equipped with TV and a small kitchen area on the ground floor. There is also a small lounge area on the lower ground floor, which used as a non-smoking, quiet lounge, equipped with TV and computer. The main kitchen is on the lower ground floor and opens into a spacious garden. The floor covering in the lower ground floor kitchen is marked and is looking worn and is in need of replacing. The cause of the damp/water damage to the ceiling of the ground floor hallway has been investigated since the last inspection and is now in need of redecorating. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 17 There are adequate numbers of toilet and bathroom facilities in the home. The floor coverings in all toilets and bathrooms are still in need of replacing and the manager has been negotiating this with Octavia Housing Association who is responsible for maintaining the communal areas. The floor covering in some areas are torn and are curling up, which poses as a health and safety risk. This has been an ongoing requirement since October 2003 and immediate action is required to ensure that this requirement is fully met. . There is an exposed central heating pipe on one of the landings which needs to be covered as it potentially a health and safety risk. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 There is a stable and committed staff group working at the home that communicate well with each other. Staffing levels permit a minimum of two staff on duty between the hours of 9am and 9pm. EVIDENCE: On the morning of the inspection there were two members of staff on duty and one member of staff was off sick. The rotas and contracts of terms and conditions between the home and the service user outline that between the hours of 9am and 9pm, there is a minimum of two staff on duty. There is always one staff sleeping in at the project during the night. Service users at the home benefit from a stable staff group, which consists of one Manager, one Deputy Manager and four senior social care workers. Proposals are in place for employing a support worker on a full time basis (37.5 hours per week). Their duties would include supporting service users with cooking, cleaning and shopping. The home does not use agency staff to fill any voids due to a number of experienced staff members being available from MACA’s temporary bank. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 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 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 & 42 The current manager is suitably qualified for the role and must submit an application to register with the CSCI. Health and safety checks are carried out regularly by staff. The home’s gas certificate has expired and must be renewed immediately. Although thermostatic mixer valves have been fitted to regulate water temperatures in the home, staff are required to test the water temperatures to ensure water is delivered at safe temperatures. EVIDENCE: The current Manager commenced employment on the 4th October 2004. The manager has a Bachelor Degree in Human and Social Services from the USA and has experience of working within the mental health setting at a supervisory level. The Manager has also been working as a Child and Adult Protection investigator also in the USA. The Manager has an application form for registering as the Registered Manager with the Commission. This application needs to be submitted to the Commission’s Central Registrations Team. This remains a requirement from the last inspection. RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 20 There are ongoing self-monitoring processes in the home, which include monthly visits from the registered provider. The Manager explained that since the last inspection, a new audit process has been developed. The home is due to have its annual full audit of the service against the National Minimum Standards next month. From then on, each month, the assessor will assess the home’s ability to meet a group of standards and will continue to do so each month until all the standards have been assessed. Another annual audit will then take place. Health and Safety documentation was checked as part of the inspection. Since the last inspection, the manager has arranged a visit from the Fire Authority and the Environmental Health Officer. Quarterly health and safety audits are completed, and staff complete daily health and safety checks on the building. The Gas and Electricity certificates have been obtained since the last inspection. The current gas certificate has expired and an immediate requirement was made to ensure that the gas is tested. Fire alarms are tested weekly and there was a certificate in place as evidence that the fire equipment has been tested recently. The portable electrical equipment was tested on the Thermostatic mixer valves have been fitted to regulate water 7th July. temperatures in the home. Staff have not been testing the water temperatures to ensure that the valves are working and delivering safe temperatures. The inspector made an immediate requirement to ensure that water temperatures are tested weekly (or more frequently if staff suspect a fault). RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 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 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 2 x x Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 RANDOLPH AVENUE (248) Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 x 3 x x 2 x G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 22 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 23 Regulation 13 [6] Timescale for action All staff must be familiar with the 1st content of the local multi-agency September 2005 policy for the protection of vulnerable adults. The damp area to the ceiling of 1st the ground floor hallway must be September re-decorated. 2005 The exposed central heating pipe 1st on one of the landings needs to September be covered as it is potentially a 2005 health and safety risk. The floor coverings in all toilets 1st and bathrooms must be September replaced. This requirment has 2005 been ongoing since October 2003 and is now being repeated for the third time. The floor covering to the lower 1st ground floor kitchen must be November replaced. 2005 An application must be 1st submitted to the Commission for September a Manager to register as the 2005 Registered Manager of the home. This is a repeat requirement. The Gas supply in the home 1st August must be tested and an up-to2005 date certificate must obtained. Water temperatures must be 25th July recorded weekly (or more 2005 frequently should staff suspect a Version 1.40 Page 23 Requirement 2. 3. 24 24 23 [2] (d) 13 [4] (c) 4. 27 16 [2] (c) & 23 [2] (b) (d) 5. 6. 28 37 23 [2] (b) (d) Care Standards Act 23 [2] (c) 13 [4] (c) 7. 8. 42 42 RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc fault). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 24 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 RANDOLPH AVENUE (248) G60-G09 S10866 RANDOLPH AVE UIV229400 180705 STAGE 4.doc Version 1.40 Page 25 - 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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