Inspection on 03/11/05 for Richford Gate, 52

This inspection was carried out on 3rd November 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 no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Richford Gate, 52 28/04/08

Richford Gate, 52 23/07/07

Richford Gate, 52 09/05/06

Richford Gate, 52 01/04/05

Richford Gate, 52 20/01/05

Richford Gate, 52 07/07/04

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 Richford Gate, 52 52 Richford Gate Richford Street Hammersmith London W6 7HZ Lead Inspector Jacqueline Derbyshire Unannounced Inspection 3rd November 2005 09:30 Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Richford Gate, 52 Address 52 Richford Gate Richford Street Hammersmith London W6 7HZ 020 8749 0307 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Yarrow Housing Ms Judy Miller Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st April 2005 Brief Description of the Service: 52-53 Richford Gate is a registered care home providing accommodation and personal care for eight men and women with a learning disability. Kensington housing trust owns the property and Yarrow Housing a voluntary organisation provide the care. The home is located between Hammersmith and Shepherds Bush and is close to transport links and local facilities. The home is made up of two flats each one housing four service users; the home is on two floors and would not be accessible for a person who has mobility problems. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site inspection that took place on Thursday 3rd November 2005. The inspector spent 3.30 hours looking at 2 service user files and 2 staff files to check all relevant documentation was in place. The finance records were checked and all transactions were seen to be recorded appropriately. The inspector spent time talking to service users and staff, a full tour of the home was given and 4 service users bedrooms were seen. The home is need of decorating in some areas specifically communal areas. There is sufficient furniture in all communal areas. There is an issue at present with the medication procedure as numerous errors have occurred in the last three months, it is a requirement that all staff make sure that the medication procedure is adhered to at all times. The inspector was notified that the air conditioning and ventilation issues in the home has still not been addressed, another repeat requirement has been set for the organisation to meet as staff and service users have all complained regarding this very important issue. There have been 10 new requirements set at this inspection. What the service does well: What has improved since the last inspection? All staff are up to date on Protection of Vulnerable Adults (POVA) awareness training. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 6 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. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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): 2 The home has an assessment procedure in place to follow when any new prospective service user is being considered. EVIDENCE: The inspector looked at two service user files that had initial assessment records in place that were completed on the individuals prior to moving into the home. These records showed that all areas of the person’s health and social needs with any risk factors were looked at and care plan was written up to show how the home would meet the needs. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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): 6,8,9 and 10 The systems for service user consultation are adequate with evidence that indicates that service users views are both sought and acted upon. There is a confidentiality policy and procedure in place at the home that is known to staff. EVIDENCE: The inspector looked at two service user files and the information was very detailed with relevant up to date care plans in place for each person. The plans reflected individual assessed needs and choices and planned interventions and were developed where required with service users families/advocates, care managers and key workers. The organisation’s risk management systems are well implemented. The assessments included general health and safety issues and risk factors for each service user. The records showed that staff liaise very closely with other professionals to enable them to meet the needs of the service users. The inspector spoke with 3 service users who stated they were happy with the care and assistance given to them by the staff and one service user stated they were very involved in their Person Centred Planning meetings (PCP). Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 10 The home has a confidentiality policy and procedure in place that is adhered to by all staff, records are locked away in the office and all staff requires a password to use the computer. One service user spoken with stated that they felt able to talk to staff if they have any issues and would be happy sharing information with them, as they felt comfortable that they would not break their confidence. Staff spoken with stated that if any confidence were to be breeched they would not do it unless there was a risk situation and the person would be notified that they would have to disclose this information to a relevant person. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 17 All service users have an appropriate leisure activities plan in place. The meals offered by the home are good offering choice and variety, staff and service users have had training in food nutrition ensuring the right nutrients are provided. EVIDENCE: All of the service users have a full activity plan that was written in their files and also on the notice board in the office. In discussion with 3 service users 2 of them stated they were happy with the activities they did. 3 of the service users have been attending college. Staff members agreed that the activity plans for all service users were discussed at all reviews meetings to ensure that the service users were stimulated and enjoyed what they were doing. All of the service users went out to do a variety of activities during the inspection including going to college and shopping. The Manager needs to make sure that a male member of staff is on duty when a specific male service users activity plan states that he will be taken on an outing as written in the persons risk assessment. Meal times are generally flexible to fit in with activities and individual choices. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 12 There is a weekly menu recorded that has very little information recorded, service users choose their own meals with staff assistance this is to ensure nutrition is balanced. The Manager needs to ensure that sufficient fresh produce is available including fresh fruit, a service user requested certain foods for breakfast and these were not available. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The systems for the administration of medication are clear; arrangements are to be put in place to ensure service users medication needs are met. EVIDENCE: The inspector looked at the (MAR) medication administration records that had recording issues. There have been numerous medication administration errors in the last three months, it is a requirement that staff follow the medication procedure correctly and that the Manager regularly monitor the records. A requirement has been set that includes two members of staff sign the MAR sheet to eliminate any administering problems. The training and development programme was checked and there is an issue that medication training has not been offered since 2004. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Staff have a very good understanding of Adult Protection issues. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. There have been issues with two of the service users behaviour towards other service users POVA meetings have been attended by all relevant professionals, these meetings are ongoing to ensure the relevant actions are best for the individual and the other service users. Service users finances were well managed and accurate records were kept. The finance records for two service users were checked. Each contained a record of all income and expenditure. Receipts were obtained for all transactions and the records were regularly balanced and checked by the home’s Manager and key workers. The complaints records were checked and there have been 5 complaints in the last 12 months, 5 of the complaints were from service users for various reasons. All of the complaints had actions completed and all were substantiated. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28 and 30 The standard of the environment within the home is adequate; some areas are in need of redecorating. The ventilation in the home is not acceptable as temperatures sore in the summer months. EVIDENCE: The property was converted to provide two flats, each for four people. Located on the first floor, there is a passenger lift and level access to both flats. However, the flats are not suitable for people with a physical disability or limited mobility as steep stairs have to be negotiated to reach bedrooms and bathroom / toilet facilities. The inspector had a full tour of the home and looked at four of the service users bedrooms. The bedrooms were adequately decorated with one bedroom in need of decorating with new curtains/net curtains required. Three of service users had their own personal items making the bedrooms homely and comfortable. The communal areas are need of decorating with carpets and curtains requiring cleaning or if in a bad state of repair replacing. The furniture in the home is adequate. The communal areas were seen to be clean and tidy, service users stated they assist by cleaning their own rooms and service users were seen to be tidying up after themselves. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 16 There is an ongoing issue with ventilation in the flats that the organisation have to provide an environment with appropriate ventilation that is acceptable for service users and staff and complies with Health and Safety and Welfare Regulations 1992. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 36 Staff showed a good knowledge of their roles and responsibilities, the team all have an ongoing training and development plan that ensures they provide relevant up to date care and have a clear understanding of their service user needs. Supervision sessions are given to all staff on a regular basis. EVIDENCE: The inspector looked at the homes rota that showed sufficient staff are on duty at all times. There are three vacancies for Support workers at the home at present these vacancies are covered by agency and bank staff. Staff meetings take place on a monthly basis the inspector looked at minutes and any issues raised had an action plan to show how the staff team were going to meet the issues. In discussion with staff it was stated that they have regular supervision meetings and annual appraisals. There is an issue that a male service user cannot be escorted out on outings by female staff, the Manager must make sure that when the service user activity plan shows that he is to go out there must be a male member of staff on duty because of the risk assessment. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 18 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): 39 and 42 The home does have monitoring tools in place, the organisation needs to collate all of the information and produce an annual Quality Assurance report. The Manager is well supported by staff to ensure all health; safety and welfare issues are met. EVIDENCE: The Home has continuous self-monitoring in place to show how they are constantly trying to improve on the service offered to service users. The inspector saw questionnaires that had been returned from service users and their families that stated how they felt about the provision of care from the home. The organisation needs to collate all information and produce an annual report of which a copy should be made available to the service users and the CSCI. The inspector felt that the home was very open and friendly, staff and service users were working very closely. Records were checked for the fire alarm and fire drills, all other records ensuring the health, safety and welfare of service users were checked. There is an ongoing issue regarding the ventilation of the home and the inspector has liaised closely with The Head of Housing for Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 19 Yarrow. There have been no improvements to the ventilation and service users and staff had an uncomfortable summer when the home was extremely hot. Both service users their families and staff have complained nothing has yet been done to rectify this problem. Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x 2 x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 3 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Richford Gate, 52 Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000019146.V272978.R01.S.doc Version 5.0 Page 21 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 YA24 Regulation 23. (2) (p) 16 Requirement Ventilation suitable for service users and staff is provided in all parts of the home.This is a repeat requirement. The home to provide fresh fruit at all times and also to have a sufficient supply of fresh produce to offer variety to the service users. The Manager to make sure menus are more informative and show a variety of nutritious balanced meals. The Manager to make sure that all staff are up to date with medication training and that the procedure for administering medication is countersigned by two members of staff to eliminate errors. The office desk and cupboard to be repaired or replaced for the safe storage of information. All curtains/net curtains to be cleaned and in some rooms replaced. All communal areas to be decorated, as paintwork is looking shabby. All carpets to be cleaned DS0000019146.V272978.R01.S.doc Timescale for action 31/12/05 2 YA17 07/11/05 3 YA17 16 11/11/05 4 YA20 13.2 21/11/05 5 6 7 8 YA24 YA26 YA28 YA28 23 16 23 23 04/02/05 20/12/05 20/12/05 20/12/05 Page 22 Richford Gate, 52 Version 5.0 9 10 11 YA26 YA39 YA39 23 24 24 especially in communal areas. Carpets in a bad state of repair to be replaced. Service users bedrooms that are in a bad state of repair to be decorated. The organisation to produce an annual quality assurance report specific to this home. PIC visit reports to be completed and a copy sent to the CSCI. 20/12/05 31/12/05 31/12/05 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 Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 23 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 Richford Gate, 52 DS0000019146.V272978.R01.S.doc Version 5.0 Page 24 - 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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