Inspection on 06/02/06 for Randolph Avenue, 248

This inspection was carried out on 6th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

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 18/07/05

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 Inspection 6th February 2006 10:25 Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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 Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Randolph Avenue, 248 Address 248 Randolph Avenue London W9 1PF 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) 020 7625 8975 020 7624 8948 www.together-uk.org Together Working for Wellbeing Mr Olalekan Yusuf Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th July 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 Together Working for Wellbeing 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 DS0000010866.V282465.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place on the 6th February 2006 over four and a half hours. The inspector spoke with three service users and checked a range of documentation and viewed communal areas. What the service does well: What has improved since the last inspection? What they could do better: Currently the home is without a permanent manager and the home is being managed by the deputy manager. Steps must be taken to formally notify the CSCI of the changes in the management and outline the arrangements in place for managing the home in the absence of an appointed Manager. A Manager must be recruited as soon as possible to manage the project and the appointed person must submit an application to the Commission to register as the Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 6 Registered Manager of the home. Once known the details of the appointed manager must be included in the home’s information pack. Steps must be taken to fix the kitchen units and drawers and consideration must be given when replacing the units to replace with better quality, more robust units. The floor covering to the lower ground floor kitchen must be replaced and this requirement is being repeated. 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 DS0000010866.V282465.R01.S.doc Version 5.1 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 Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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 the following standard(s): 1,2,4 Comprehensive information is available about the project’s aims and objectives and facilities. This provides prospective service users with clear information to enable them to make an informed choice about living at the home. The details of the new manager needs to be included when known. The referral process is clear and good information is available on the needs of the service users. EVIDENCE: The home’s statement of purpose and service user’s guide was available and seen during the inspection. The information is comprehensive and clearly outlines the aims of the project, which is to provide a structured, rehabilitative accommodation for a maximum period of two years. Service users spoken with during the inspection were aware of the aims of the project. The information needs to be updated with details of the new manager once available. Currently there are two service users who have been referred for admission to the home. The referral information was seen during the inspection. Full needs assessments and risk assessments are in place for the service users, and correspondence with referring agencies and other professionals is clearly documented. There was evidence on file that the service users have visited the home. The client’s impressions of the home and the staff’s impressions of how the visit went are documented. The staff of Randolph Avenue conduct their own assessment of service users’ needs which includes an assessment of the service users’ commitment to take part in the rehabilitation programme. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Service users are involved in the care planning process and the individual care plans provide good, up-to-date information about service users’ needs. Risk assessment and management plans are regularly updated and are comprehensive. EVIDENCE: The files of three service users were checked during the inspection. Each service user has a care plan outlining their needs including mental health needs, medication and general health and daytime activities. The plans had been signed by the service users and are regularly reviewed. Each service user has a key worker who meet with them to discuss their progress against their care plan. The statement of purpose states that staff offer weekly key working sessions. Service users’ records did not demonstrate this and it is a recommendation that weekly key working sessions are offered as outlined in the statement of purpose. Daily contact notes are maintained and provide a good insight into the life of the service users. There are risk Management plans in place for each service user. These plans provide a good level of information and identify warning signs, risk factors and actions to be taken. Risk assessments are reviewed on a three monthly basis or more frequently if changes occur. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 10 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): 16 Service users are supported to develop their independent living skills through structured programme of activities. Service users rights and responsibilities are clear. EVIDENCE: As discussed earlier in the report, the aim of the project is to provide a structured programme, which encourages the service users to develop their independent living skills. At the end of the two years, the aim is for the service user to have the skills for living in a more independent setting. Service users’ have responsibilities for cleaning, cooking, attending to their laundry and food shopping. Their responsibilities are outlined in their individual plans. Service users have unrestrictive access to all communal areas in the home. Each service user has a contract of terms and conditions of living in the home and includes the rules on smoking, alcohol and drugs. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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): 19, Service users’ needs with regards to personal care is outlined in their individual care plan and their preferences are respected. EVIDENCE: The service users’ needs with regards to personal care are outlined in the individual care plans. Some service users are independent with their personal care; others require some prompting in this area. Times for getting up and going to bed are flexible depending on the activities planned for the day. Service users are able to choose their own clothes, which reflects their personality. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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): 22,23 There is an accessible and well-published complaints procedure in place. Staff have access to policies for protecting service users from abuse, neglect and self-harm. EVIDENCE: No new complaints have been made since the last inspection. The home’s complaints policy is in an accessible format and was on display on the home’s notice board at the time of the inspection. Service users spoken with during the inspection felt satisfied with the support they were receiving from staff and did not have any concerns with the way the home was managed. The multi-agency’s policy for the protection of vulnerable adults was available on the day of the inspection. Staff have access to the Westminster City Council’s training programme, which includes the Protection of Vulnerable Adults training. The individual risk management plans identify any service users who are of potential risks of self-harm and outline steps to take for early detection and protection. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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, 27,28,30 The home is suitable for its purpose, it is safe and comfortable. Some aspects of the environment has improved since the last inspection but the kitchen floor is in need of replacing and remains a requirement. Overall, the home was clean and hygienic. EVIDENCE: Randolph Avenue is a large, terraced, five-storey Victorian building situated close to the local amenities of Maida Vale. The communal kitchen and lounge areas were viewed during the inspection. On the ground floor, there is a lounge equipped with a small kitchen area. Service users are able to spend time in here watching TV, DVD’s, listening to music and socialising. This is the main lounge area and smoking is permitted in here. On the lower ground floor there is a small lounge, which is used as a nonsmoking lounge area and is equipped with TV and computer. The main kitchen is on the lower ground floor and opens into a spacious garden. The inspector noted that the lower ground floor kitchen area and main lounge have recently been painted. The floor covering in the lower ground floor kitchen is very marked and is need of replacing. This requirement is repeated from the last inspection. The kitchen units are of poor quality with doors frequently falling off their hinges Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 14 and drawers broken. Steps must be taken to fix these units and consideration must be given when replacing the units to replace with better quality, more robust units. The cause of the damp/water damage to the ceiling of the ground floor hallway identified at the last inspection visit has been identified and the ceiling has now been re-decorated. The floor coverings in all toilets and bathrooms have been replaced and the exposed central heating pipes on the landing has been covered and made safe. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 15 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): 32,34,35,36 The staff team are aware of the service users’ needs and are well supported and supervised by the deputy manager. The home’s recruitment procedures are sufficiently thorough for ensuring that staff employed are suitable for working with vulnerable adults. EVIDENCE: Staff have access to the organisation’s training programme and the training programme of Westminster City Council. New staff receive induction training which includes Protection of Vulnerable Adults training. Staff have attended training relevant to the service user group including challenging behaviour, drugs and alcohol awareness, violence and aggression and human rights. Currently the deputy manager is in the process of studying to be an NVQ assessor and three of the permanent members of staff are currently undertaking training in NVQ level 3. It is a recommendation that a training needs analysis is drawn up for each staff member highlighting when updates in mandatory training are due. The organisation’s regional office is responsible for the recruitment of new staff. Staff at the regional office complete all pre-employment checks, which include CRB and POVA checks, health checks and references. Copies of the reference checks are sent to the home and confirmation that the medical checks and CRB and POVA checks are satisfactory is sent to the home. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 16 The home’s deputy manager is responsible for supervising the staff team. Currently one-to-one supervision takes place every 2-3 weeks and includes key topics for discussion including key clients, areas of responsibilities and training. Annual appraisals also take place. A six month probation period is offered to new staff and a meeting is held following three months and five months of commencing to discuss competence and to confirm role and set new goals. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The home is without at permanent manager. Steps must be taken to appoint another suitably qualified person to manage the home. Good quality assurance systems are in place involving service users. EVIDENCE: The inspector was told on the day of the inspection that the manager has resigned and left their employment. The post is currently being advertised. Together must ensure that a competent manager is employed and that the appointed person is registered with the CSCI’s Central Registrations Team. The home is currently managed by the Deputy Manager. She is experienced and competent and understands the needs of the service users. The Service Manager also provides support to the project and aims to visit fortnightly. The quality assurance systems in the home are thorough and include the process of ongoing self-monitoring. Thorough visits on behalf of the registered provider are undertaken where the person assesses the overall quality of the service. As well as this visit, each month, a quality assurance check is completed against a set of standards. Different standards are assessed monthly and then an overall audit of the service against the National Minimum Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 18 Standards is completed annually. Results of service user questionnaires are compiled and published in the service’s annual plan. Health and safety documentation was seen during the inspection. Quarterly health and safety audits take place; health and safety checks of service users’ rooms are undertaken monthly and daily health and safety checks are undertaken on the building. Electricity and gas certificates are available and valid. A certificate was seen by the fire authority confirming that following an inspection, the premises are fit for purpose. A fire risk assessment is also in place. Water temperatures are measured weekly to check that the thermostatic mixer valves are working and delivering water at safe temperatures. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 19 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 3 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 3 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 x x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 x x 2 x 3 x x 3 x Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 20 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 Standard YA1 YA28 Regulation 4 [1] (c) Schedule 1 16 [2] (h) Timescale for action Details of the appointed manager 01/05/06 must be included in the home’s information pack. Steps must be taken to fix the 01/04/06 kitchen units and drawers and consideration must be given when replacing the units to replace with better quality, more robust units. The floor covering to the lower 01/07/06 ground floor kitchen must be replaced. This requirement is being repeated. The CSCI must be formally 15/03/06 notified of the changes in the management and the arrangements in place for managing the home in the absence of an appointed Manager. A Manager must be recruited to 01/04/06 manage the project. An application must be 01/05/06 submitted to the Commission for the appointed Manager to register as the Registered Manager of the home. Requirement 3 YA28 23 [2] (b) (d) 4 YA37 39 5 6 YA37 YA37 8 Care Standards Act Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 21 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 2 Refer to Standard YA6 YA32 Good Practice Recommendations Weekly key working sessions should be offered as outlined in the statement of purpose/service user’s guide. A training needs analysis should be drawn up for each staff member highlighting when updates in mandatory training are due. Randolph Avenue, 248 DS0000010866.V282465.R01.S.doc Version 5.1 Page 22 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 DS0000010866.V282465.R01.S.doc Version 5.1 Page 23 - 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. 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