Inspection on 10/10/07 for Shirland Road, 93-95

This inspection was carried out on 10th October 2007.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirland Road, 93-95 23/06/06

Shirland Road, 93-95 24/06/05

Shirland Road, 93-95 19/01/05

Shirland Road, 93-95 02/07/04

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

CARE HOME ADULTS 18-65 Shirland Road, 93-95 93/95 Shirland Road London W9 2EL Lead Inspector Wynne Price-Rees Key Unannounced Inspection 10th October 2007 10:30 Shirland Road, 93-95 DS0000010874.V344732.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 Shirland Road, 93-95 DS0000010874.V344732.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. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirland Road, 93-95 Address 93/95 Shirland Road London W9 2EL 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 7266 0161 020 7289 3050 Rachely@MUNGOS.ORG St Mungo Association Ms Rachel Elizabeth Yates Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2006 Brief Description of the Service: 93 - 95 Shirland Road is a residential care home providing accommodation for eighteen homeless men and women with mental health support needs. There is a current occupancy of seventeen. The property is owned by Paddington Churches Housing Association and the care is provided by St Mungo’s, a voluntary organisation. The home is located in a residential area of Maida Vale, close to shops and transport links. It is accessible to people in wheelchairs. The home works closely with the Joint Homelessness Teams (JHT) in Westminster and Kensington and Chelsea and all referrals come from these teams. The home provides medium term placements, usually for up to 18 months, preparing people to move on to more independent accommodation. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over five hours on one day. During the inspection care practices were observed, three residents case tracked, records and procedures checked and a premises tour carried out. Residents and staff were also spoken with. An AQAA was returned prior to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The fridge and freezer temperatures must be checked and recorded on weekends and emergency lighting tested and recorded weekly even if the health and safety representative is not available. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shirland Road, 93-95 DS0000010874.V344732.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 Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. Residents fully assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents’ handbook has been updated and contains comprehensive information about living at the home, service provided and local amenities. The home has a thorough written assessment procedure that two residents files case tracked revealed is followed. All referrals are made by Westminster City Council who has a block contract with the home. Good quality information is forwarded to the home including most up to date available care plan, adult mental health assessment and risk assessment. The staff team discuss this information and their own assessment before deciding if needs could be met and a placement would be appropriate. If the outcome is positive the prospective client is invited for a short visit and then a three-day stay to determine if they want to move in and further identify if their needs can be met. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. A suitable chosen lifestyle is enabled. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The three files case tracked demonstrated that care plans are generated from the original assessment that identifies needs, wishes and how to meet them from which goals are established. These take the form of identified separate resident and staff goals and action plans that work in tandem and are underpinned by regularly reviewed risk assessments that enable goals to be achieved. Although the goals are individual, they all work towards the common aim of eventually enabling a resident to live independently. The speed with which this is achieved depends on the individual and level of life skills they have achieved. The level of care planning involvement is a matter of personal choice with some residents’ typing up their own care plans. Monthly care plan reviews take place that feed statutory quarterly reviews with the placing authority. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 10 Residents’ are encouraged and supported to make their own decisions on a daily basis to progress towards independent living within a risk-assessed environment. They decide what activities they wish to participate in with one client attending a photography group on Mondays and Thursdays on alternate weeks. Another resident is deciding if they wish to have a flexi-carer or not to encourage more participation in activities. Most residents are responsible for handling their own financial affairs with support as required. The local authority is appointee for two residents. The home holds monthly meetings where residents are encouraged to make suggestions regarding how the house runs, any activities they would like to pursue and discuss any grievances. A suggestions notice board has also been put up in the dining area so that people, who would prefer not to put forward their views in a public forum, can have their say anonymously. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. Personal & health care delivered appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home encourages the personal development of individuals by supporting them to undertake a wide range of activities suited to them within work and social environments. Whilst encouragement and support is given it is still up to the individual to decide what they want to do, when and how often. The activities vary between volunteer work in a Salvation Army homeless centre, preparing a CV to become a Russian translator and interpreter and attending college courses for cookery, African drumming, literacy and maths and English GCSE. Good use is made of local facilities such as day centres, parks, cafes and local shops. Some residents’ use local cafes to carry out care plan reviews with their key-workers. There have also been a number of visits to places such as Blue Water, the London Dungeon, boat trips and museums. A group trip to Norwich Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 12 is planned for later on in the month and five residents’ have recently returned from a holiday at Centre Parcs. Daily house routines are fitted around the needs of the individual rather than the other way around. Residents are responsible for looking after their own rooms as part of life skill development. They decide if they would prefer to eat as a group or individually with menus reviewed during house meetings. Recently the residents decided they would prefer a longer breakfast time and this has been introduced. The house rules are based on health, safety and respect for other people and their property. They are contained in the residents’ handbook. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 21. Quality in this outcome area is good. Residents personal and health needs are safely met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal care is provided if required although this generally takes the shape of prompting residents’ to attend to their own personal hygiene. All residents’ are registered with GPs except one who refuses to register. They are also offered annual check ups. They have full access to community based health services and are supported to access them, by staff, as required. Community Psychiatric nurses visit when needed. The individual’s health care needs are identified and addressed as part of the care planning system. There is a written policy and procedure regarding medication administration and only those qualified to do so administer. There are three residents currently self-medicating with differing levels of support. No controlled drugs are kept on the premises. The MARR sheets were checked for all residents and found to be accurately filled in. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. Residents are protected, listened to & complaints investigated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a written complaints policy and procedure that residents confirmed has been explained to them and is contained in the handbook. Records of complaints made are kept and include outcomes. Residents are encouraged to make entries in the complaints book themselves. The records are also used as part of the quality assurance system. All staff have received mandatory adult protection training as part of induction, which is regularly updated. There are also procedures regarding action to take if abuse is encountered and these include a policy regarding aggression on the part of a resident. All staff are CRB and POVA cleared prior to commencing employment. There are currently no out standing POVA issues. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30. Quality in this outcome area is good. Appropriate accommodation is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises found the home was suitable for its stated purpose. Walk in showers have been fitted since the last key inspection to meet the needs of clients who are unsteady on their feet. The home itself was comfortable, homely and safe. The home was clean and hygienic. There were up to date building risk assessments. The fire alarm and emergency lighting are tested weekly, fire drills take place quarterly, there is an evacuation procedure that residents’ and staff are familiar with and the fire appliances were checked and serviced on 09/07/07. The fire alarm was serviced on 22/08/07, PAT tests carried out on 26/04/07 and lift serviced on 28/02/07. Health and safety risk assessments are updated annually and fire doors fitted with automatic closures. The fridge and freezer temperatures are checked daily during the week although this does not seem to be taking place on weekends. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 16 There was also a gap in recording of the weekly emergency lighting when the health and safety representative was off sick. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is good. Efficient, qualified & capable staff are in sufficient numbers to meet needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Currently there are no staff vacancies. Of the eleven care staff, one is undertaking NVQ level 2 and the other ten have already attained it or above. The duty rota for September was inspected and indicated there are adequate numbers of staff on duty at all times to meet residents’ needs. The staff spoken with were very knowledgeable regarding the client group they provide a service for and obviously committed to providing the best service possible for residents in a friendly, caring and supportive way. Good care practices were observed during the course of the inspection including when staff were unaware the Inspector was present. Staff meetings take place weekly and supervision monthly. Staff receive induction training and have access to a rolling training programme with training focused on areas identified for attention in supervision and during annual appraisals. Team training targets areas the team feel they need to concentrate on as part of annual planning. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 18 The organisation has a thorough recruitment procedure that protects clients and meets all the criteria of the standard. All staff are CRB checked and there are currently no POVA issues. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. The home is well run in residents’ best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Care manager has extensive experience in the care field, focused on mental health and holds an NVQ 4 diploma in management of care studies. The residents spoken with felt the home was well run with their interests to the fore. There is an identified health and safety officer and full health and safety risk assessments are carried out. The quality assurance system operated within the home and by the organisation picks up shortfalls in the standards. The quality assurance system contains measurable performance indicators that are regularly reviewed. Part of the system is for homes to audit each other and this is carried out by staff with specific training for this task. Monthly provider visits also take place. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 20 Quarterly monitoring also takes place in conjunction with the Westminster Supporting People Team. Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA30 Regulation 16 (2) (g) & (h) Requirement The fridge and freezer temperatures must be checked and recorded on weekends and emergency lighting tested and recorded weekly even if the health and safety representative is not available. Timescale for action 01/12/07 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 Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shirland Road, 93-95 DS0000010874.V344732.R01.S.doc Version 5.2 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. 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