Inspection on 30/08/06 for Richford Street, 60

This inspection was carried out on 30th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Richford Street, 60 26/06/08

Richford Street, 60 23/10/07

Richford Street, 60 01/09/05

Richford Street, 60 05/10/04

Richford Street, 60 01/06/04

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 Street, 60 Richford Street 60 Richford Street Hammersmith London W6 7HP Lead Inspector Jacqueline Derbyshire Unannounced Inspection 30th August 2006 09:30 Richford Street, 60 DS0000019139.V306449.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 Richford Street, 60 DS0000019139.V306449.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. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Richford Street, 60 Address Richford Street 60 Richford Street Hammersmith London W6 7HP 020 8749 9295 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 Limited Mr Lawrence Matthew Dawson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Board and care The number of persons for whom residential accommodation with both board and care is provided at any one time shall not exceed 3 people with learning disability 1st September 2005 Date of last inspection Brief Description of the Service: 60 Richford Street is a registered care home providing accommodation and personal care for two women with a learning disability; there is also a vacancy at the home at present. Shepherds Bush Housing Association owns the property and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home is located in a residential area, close to the shops and transport links of Shepherds Bush and Hammersmith Broadway. The accommodation is arranged over three floors the ladies bedrooms are situated on the ground floor with the vacant room on the 1st floor. The home has a back garden that is used by the service users. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site inspection; the inspector spent 3.30 hours looking at records and documentation and talking to two service users, and a member of staff. One-service users care plan and risk assessments were checked. A full tour of the house was given and two of the service users bedrooms were seen. The service users finance records and medication were checked by the Inspector. The Manager was not available on the day of the Inspection and there was no access to staff records. The senior member of staff on duty was very helpful in providing all of the relevant information. On the morning of the Inspection one of the ladies had a Doctors appointment and only one member of staff was on duty, that meant one service user would have been left in the house on her own. This would have been in breech of the homes risk assessment and a health and safety issue. This issue was dealt with straight away by the member of staff after discussion with the Inspector and a member of staff was sent from another Yarrow home close by. There is a repeat requirement regarding records being archived off site, this is a fire risk and needs to be implemented in the requirement timescale by the organisation. There are 12 new requirements set from this Inspection. What the service does well: What has improved since the last inspection? Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 6 One of the service users that lived at the home for a long period of time moved out to a more suitable home that could meet all of his healthcare needs due to a debilitating illness. 4 of the 6 requirements set at the Inspection 01/09/05 were set regarding the inappropriateness of the service user staying at Richford Street. The Manager and staff did an excellent job of caring for the service user and it was written in the homes communication book that staff and the two ladies had recently visited him at his new home. New sofas are now in the lounge and the ladies stated that they liked them and they are very comfortable. 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 Street, 60 DS0000019139.V306449.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 Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards in this section were looked at in this inspection as all of the service users have lived at the home for a number of years. EVIDENCE: Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Person Centred Planning (PCP) records are all up to date with a lot of information in place some of the information is in photographs chosen by the service users. These plans are put in place with the service user whose input is sought throughout the process; this ensures the care plan is what the service user requires from the home. EVIDENCE: One service user file was looked at and had up to date information in place. In the Person Centred Planning (PCP) document there was a lot of information with specific aims for the person to be met in a six month period or before if possible. One of the aims was to go on holiday with the other service user; records show that this took place in July 2006. Both of the service users stated they had a good time and enjoyed their holiday together. Review records were all up to date with records showing how aims have been met. The two service users living at Richford Street are assisted by staff to be as independent as is practicable with risk assessments in place for any risk areas. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 10 There was on issue on the day of the Inspection that one of the service users had a Doctors appointment, there was only one member of staff on duty when the Inspector arrived who was going to escort the service user. This meant that one of the service users would have been left in the house on her own, this did not correspond with a risk assessment stating that the ladies would not like to be left on their own at any time in the house. This would also breech health/safety and welfare regulations. Another member of staff was sent from a home close by to Richford Street to be in the house. In discussion with the member of staff it was stated that a student was arriving shortly and that he did not have the authority to request extra staffing to assist in these circumstances. Requirement have been set to ensure that the person in charge has the authority and that the ladies must never be left on their own in the house. Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Links with the community are good and support to enrich service users social and educational opportunities are in place. EVIDENCE: One of the service users has a full activity plan that was written in their file and also on the notice board in the kitchen. Both of the service users go out daily to a local café usually twice daily. One of the ladies also attends The Gate for art and drama classes, keep fit classes and sewing classes she also has a part time voluntary job there cleaning every afternoon Monday-Friday, which she stated she really enjoys doing. The other service user has not got such a full activity schedule. In discussion with a member of staff it was stated that the service user does enjoy going on outings to the shops, museums and other places of interest, this was not reflected in her plan. Both of the service users have visitors and in discussion with a member of staff it was stated that they also visit family and friends. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 12 There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced this is done weekly. The menus for both service users are also in picture format in the kitchen. In discussion with a member of staff it was stated that they are trying to introduce a more varied menu with some continental dishes. The service users both said they enjoy their food and choose what they had to eat. Both of service users were seen to make drinks and help themselves to snacks when they wanted to. Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: The service users are independent and complete their own personal care needs. The Inspector looked at the healthcare records of one of the service users that showed she was up to date with all medical checks including optical and dental. The service user was going to the Doctors on the day of the Inspection for a follow up appointment. Both of the service users are escorted to medical appointments as they can become quite anxious. Both of the service users are very mobile and as written do go out daily. There is a repeat requirement for all old records to be archived as the Inspector spent a lot of time reading through old information before being able to read the up to date relevant information. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 14 The Inspector checked the medication administration records for both of the people living in the home. Overall the Inspector felt that the standard of medication recording was good with all staff following the medication procedure. Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaint procedure is available to all and is written in the Service user guide and was also on the notice board. There is a procedure in place at the home that is used for protection incidents that is known to service users and staff. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. Service users finances were well managed and accurate records were kept. The finance records for both of the 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 key workers and the home’s Manager. There were no complaints recorded in the last 12 months and in discussion with one of the service users she stated if she was not happy she would speak to a member of staff. The Inspector read a quality questionnaire that a service user had completed that asked if they are aware of the complaints procedure and it was stated they do and would complain if the need arose. Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is adequate providing service users with a homely place to live. EVIDENCE: A full tour of the home was given and two of the service users bedrooms were seen, they were both different with the service users individual tastes taken into account. One of the service users was happy to show the inspector their bedroom and stated they were very happy with the furniture. The vacant bedroom needs new curtains. The bathroom blind needs to be replaced as the old one has fallen off. The home was clean and the new sofas in the lounge look very nice both service users said how comfortable they are. The lounge carpet needs to be deep cleaned as it is stained. Richford Street, 60 DS0000019139.V306449.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed at this visit. EVIDENCE: Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 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): 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Inspector was only able to look at some of the health and safety areas of the home. EVIDENCE: The Inspector spent a lot of time going through files to find the relevant up to date information as written in this report the Manager needs to ensure that only relevant up to date information is in place and all old records are archived off site because of health and safety issues. The Inspector was not able to check all of the health and safety records as the member of staff and the Inspector were not able to find them. There is a requirement that the latest gas and electricity annual check certificates are sent to the CSCI. All other health and safety areas including fire alarm checks and drills take place on a regular basis with relevant records in place. There are requirements for health and safety that the Manager will have to meet in the required time. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 19 Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 2 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 x 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x x x x 2 2 x Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 Page 21 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 YA41 Regulation 17 Requirement Old records and documentation to be archived. The organisation is to implement this as it is to be done off site as there is space restraints in the home and the office is too small for the paper work that is at present stored there. This is a repeat requirement. There must be sufficient staff on duty to ensure that service users are not at any time left on their own, as written in the homes risk assessment. One of the service users to have an activity plan that includes more stimulating activities. The carpet in the lounge to be deep cleaned. New curtains to be put in vacant bedroom. A new blind to be purchased for the bathroom. The Manager to ensure that there is adequate staff on duty at all times to meet the needs of all service users. Staff who are in charge of shift to be given authority to increase staffing levels if required. DS0000019139.V306449.R01.S.doc Timescale for action 31/10/06 2 YA9 YA33 18 13 06/09/06 3 4 5 6 7 YA14 YA26 YA26 YA27 YA33 16 16 16 16 18 31/10/06 30/09/06 31/10/06 30/09/06 06/09/06 8 YA33 18 06/09/06 Richford Street, 60 Version 5.2 Page 22 9 YA41 17 10 11 12 13 YA42 YA42 YA42 YA42 13 13 13 16 The Manager to organise service user files with relevant up to date information in place. Old records to be archived. Copies of annual maintenance certificates to be sent to CSCI. The washing machine to be repaired. The Manager to make sure that fridge and freezer temperatures are taken daily. Plastic containers are supplied for safe storage of all dry food storage. 31/10/06 30/09/06 06/09/06 06/09/06 30/09/06 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 YA28 Good Practice Recommendations The garden to be tidied up as it looking slightly neglected. Richford Street, 60 DS0000019139.V306449.R01.S.doc Version 5.2 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. 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