Inspection on 23/06/06 for Shirland Road, 93-95

This inspection was carried out on 23rd June 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirland Road, 93-95 10/10/07

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 Unannounced Inspection 23rd June 2006 10:00 Shirland Road, 93-95 DS0000010874.V289231.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 Shirland Road, 93-95 DS0000010874.V289231.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. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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 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.V289231.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th September 2005 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 sixteen.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.V289231.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, took place over five hours and four residents were case tracked. A tour of the premises took place and staff and residents spoken with if they wished. What the service does well: What has improved since the last inspection? What they could do better: The clients’ handbook contains outdated information. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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. Shirland Road, 93-95 DS0000010874.V289231.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 Shirland Road, 93-95 DS0000010874.V289231.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, The quality outcome was adequate. This judgement was arrived at through an inspection visit. Clients do not have full information to make an informed choice. Clients are fully assessed prior to moving in. EVIDENCE: The clients’ handbook contained some outdated information that requires updating. Full assessment information was recorded on the files case tracked. Six new clients have moved in since the last inspection. Shirland Road, 93-95 DS0000010874.V289231.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, 7 & 9. The quality outcome is good. This was arrived at by an inspection visit. Clients have up to date care plans, risk assessments and they are enabled to make their own decisions. EVIDENCE: Four residents files were case tracked and found to contain up to date care plans that had identified goals were underpinned by regularly reviewed risk assessments and fed by progress notes and reviews. As goals are achieved, they are replaced by new ones. The residents have identified key workers and participate in care planning as much or as little as they wish. Progress notes are filled in three times per day and the goals set stated at the top of the progress notes to promote focus on them. An initial risk assessment is carried out on arrival, updated after three months and then reviewed at six monthly intervals or as required. There are also higher risk assessments that focus on possible breakdown areas related to the client’s history. House risk assessments were also in place. Monthly minuted client meetings take place and are used as a forum for discussion of ideas, grievances and to make suggestions regarding activities and menu suggestions. Staff attend including the chef and maintenance man so that areas specific to their roles can be addressed directly and to re-enforce Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 Page 10 that clients’ views are taken seriously. Current discussion topics include new décor for the TV and dining room. Residents also have the opportunity to put forward their views through the key working system and they are supported to make their own decisions within a risk assessed environment. They also have access to outside advocates and managers from the organisation visit monthly to take their views. Everyone has a bank or post office account and three are subject to appointeeship by Westminster City Council. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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, 15, 16 & 17. The quality outcome for this area was good. This was arrived at by an inspection visit. Clients take part in appropriate activities, are part of the local community, encouraged to form and maintain relationships and their rights are respected. They enjoy a healthy and varied diet. EVIDENCE: One client is attending a cook and eat course run by the Westminster Education Service that has a dual purpose of improving awareness of culinary skills and grasp of the English language as it is not their first language. Another client is attending a photographic course at Portugal Prints as well as working there two days per week as an administrator. Staff support clients to source any courses or other pursuits they have identified as of interest. A client frequents the Clubhouse mental health day service whilst another is undertaking the wood working taster class run by St Mungo’s. Good use is made of local amenities such as shops, restaurants and parks with one client making particular use of local libraries. There is now a life skills coordinator that is shared between this and another project. The maintenance and re-establishment of family links is promoted and supported. Recently one client, from a different country re-established links Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 Page 12 with their family and has now moved home. Another client has six weekly visits from their mum who lives in a different part of the country. The home’s daily routine works around the clients’ needs and wishes rather than the other way around and the house rules are based upon health and safety and respect for others and their property. Everyone has a key to the front door and their own rooms. A recent client requested that they be addressed by the prefix “Mr” and this was adhered to. Life skill development is encouraged through client involvement in tasks such as gardening with a client painting the garden furniture recently. The clients are going to embark on their own redecoration of communal areas as soon as the colour scheme has been agreed and one has redecorated their own bedroom. They are responsible for doing their own laundry and keeping their rooms clean and tidy with support. Clients make their own breakfast and participate in meal preparation. If they make sandwiches at lunchtime there is no charge. They agree a four weekly menu with options and participate in food shopping. Healthy eating and nutrition are part of the care planning process. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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 & 20. The quality outcome was good. This was arrived at through an inspection visit. Personal support is not provided. Physical and emotional health needs are met and medication is appropriately administered and recorded. EVIDENCE: The home does not provide personal care. Clients are prompted and supported to maintain acceptable levels of personal hygiene as required and this is addressed as part of the care planning process. The clients have full access to community based health services including GP practices. Each client is registered with a GP except one who has decided not to register locally. Their GP has de-registered them and alternatives are being pursued. Health care needs are addressed as part of the care plans. Following admission each client receives a health check as part of the GP’s registration process. A minimum of annual health checks are offered to each client. There are fourteen clients on medication with three self-medicating and one starting next week. The self-medicating system is staged and monitored using a blister pack system and room checks. The medication administration system was checked for all clients and found to be correctly recorded with the exception of two blank entries that had been Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 Page 14 picked up by the monitoring system and addressed. The records are checked daily by staff and monitored every two days by the Care Manager. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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 & 23. The quality outcome was good. This was arrived at by an inspection visit. Clients views are listened to, acted upon and they are d EVIDENCE: There is a written complaints procedure that is contained in the residents handbook and pinned up on the noticeboard. There is also a complaints box. The residents are aware of the complaints procedure and how to invoke it. Most complaints are resolved through key working or at the residents’ meetings that are minuted. The procedure states that they are responded to within twenty-eight days. There were no complaints recorded since the last inspection. There is an adult protection procedure that staff are familiar with and know how to initiate. Adult abuse is part of core induction training and staff are informed of what constitutes abuse and how to respond if encountered. There have been no Pova referrals since the last inspection. Staff have attended adult protection training and a separate course that outlines hoe to deal with aggression on the part of clients. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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): 24,27 & 30. The quality outcome is good. This was arrived at by a tour of the premises. Clients live in a suitable, homely environment, containing adequate facilities and the home is clean and hygienic. EVIDENCE: A tour of the premises found the home was suitable for its stated purpose, although there are no walk in showers, rather showers are provided within the baths and these do not meet the needs and preferences of clients who are unsteady on their feet. The home itself was comfortable, homely and safe. New furniture has been purchased in communal areas and as previously stated clients will be carrying out their own redecoration reflecting that they view this as their home. The flooring in some bedrooms has also been replaced. There had previously been a bed bug infestation that has now been removed and the home was clean and hygienic. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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): 32, 34 & 35. The quality outcome was good. This was arrived at as part of the inspection process. There are competent, qualified staff who are suitably trained and clients are protected by the recruitment process. EVIDENCE: Currently there is one vacancy for a fulltime project worker and this post is being advertised internally. This post and two project workers who are on long term sick leave are covered by locums from the organisation. The same locums are used wherever possible to promote continuity of care. Over 50 of staff have achieved NVQ level 2 or above and another staff member is embarking on the course in July. The staff rota demonstrated that staff ratios are adequate to meet clients needs. The organisation has a thorough recruitment procedure that protects clients and meets all the criteria of the standard. The organisation provides thorough induction training and access to a rolling training programme to meet needs identified within monthly supervision and annual appraisal. A standing supervision agenda item is the individual staff training and development plan. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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): 37, 39 & 42. The quality outcome for this area was good. This was arrived at as part of the inspection process. The residents benefit from a well run home, are confident their views underpin self-monitoring, review and development and their health, safety and welfare are promoted and protected. 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 with weekly fire alarm, call points and emergency lighting checks. The last recorded fire drill took place on 22/11/05 although one did take place in April although the report has not yet been forwarded to the home by the organisation. The next is due in October. The fire fighting equipment is checked and serviced annually and an organisational health and safety inspection took place in May. PAT tests on electrical equipment have also taken place. A sample of records and procedures showed them to be up to date and in place. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 Page 19 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. Quarterly monitoring also takes place in conjunction with the Westminster Supporting People Team. Shirland Road, 93-95 DS0000010874.V289231.R01.S.doc Version 5.1 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 2 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 2 28 X 29 X 30 3 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.V289231.R01.S.doc Version 5.1 Page 21 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 YA27 Regulation 23 (2) (j) Requirement Walk in showers must be provided as an alternative to meet the needs of clients who are unsteady on their feet. The client handbook must be updated. Timescale for action 01/04/07 2 YA1 5 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Shirland Road, 93-95 DS0000010874.V289231.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 Shirland Road, 93-95 DS0000010874.V289231.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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