Inspection on 24/06/05 for Shirland Road, 93-95

This inspection was carried out on 24th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shirland Road, 93-95 10/10/07

Shirland Road, 93-95 23/06/06

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 24 June 2005 10.15 am 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 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 Stationary 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 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Shirland Raod, 93-95 Address 93/95 Shirland Road, London W9 2EL Telephone number Fax number Email 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 Vacant Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18) of places SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19 January 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 full occupancy.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 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over four hours on the 24th June 2005. Four residents were spoken with whilst three residents decided not to speak with the Inspector. A sample of three residents’ files were case tracked. The inspection focused on the requirement of the previous visit and most core standards. The residents said they enjoyed living at the home, were satisfied with the activities, meals and the way the staff team provided support. This was reflected in the care practices observed. A number of staff were also spoken with and said the enjoyed working at the home. What the service does well: What has improved since the last inspection? The previous Care Manager has retired since the last inspection and whilst they provided a high standard of care and support, this had dropped a little until a new Care Manager was appointed at the beginning of June 2005. They demonstrated a number of areas identified that could be improved and how they intended to implement the improvement in conjunction with the staff team. There was one requirement from the last inspection regarding gaps in the administration of medication recording and this was met, at this inspection. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 2 This requirement was not met. There is a full assessment procedure that is followed before a resident can enter the home. However no referral forms or resettlement plans forwarded by the placing authority could be found. This means it takes longer for care plans to be put together and no resettlement plan means residents’ won’t be ready to move on. EVIDENCE: Three residents’ files were inspected and the admission procedure was documented as being followed. There were full assessments carried out with accompanying mental health assessments that were forwarded by the placing authority. These did not contain referral forms identifying who was making the referral and no resettlement plans. The resettlement plans are required to enable residents’ to progress towards preparation to move on once they felt confident to do so. Part of the assessment procedure is that a prospective resident visits a number of times, including two overnight visits, prior to admission. This gives them the opportunity to see if they wish to move in and staff to assess if they will fit in with the home’s community. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Standard seven was met. Standard six and nine were not met. The progress notes that inform the care plans and individual risk assessments that enable them were not clear or very in-depth, meaning they slowed down residents’ progress towards goals set. The health and safety risk assessments’ were outside review dates that could put residents’ and staff at risk. Observation of care practices, documentation and conversations with residents’ showed they are enabled to make their own decisions and improve life skills. EVIDENCE: Three residents’ case files were sampled and showed that they had goal focused care plans in place that are underpinned by risk assessments. These contained identified resident and staff goals and how they were to be achieved. However although the progress notes, that feed reviews, reflected the goals set they did not demonstrate where progress was being made. Therefore it was difficult to gauge how much progress had been made towards the overall goal of preparing residents’ for independent or semi-independent living. Individual risk assessments were in place and whilst being the platform for enabling progress, were not clear and did not contain enough in-depth information. The health and safety risk assessments had lapsed past their review dates. All three-problem areas could have arisen from the time span SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 10 between the former Care Manager leaving and the new one starting in post. The current Care Manager had also identified these areas and demonstrated the systems they intended to introduce to improve them. The residents’ spoken with said they felt empowered and encouraged to make their own decisions by staff. This was reflected in the care practices observed and minuted residents’ meetings that had taken place. These normally take place over a meal. The residents’ had also been involved in the recruitment of the Care Manager. They are also responsible for handling their own finances with support as required. All residents have their own front door and bedroom keys. Six residents’ had chosen to go on holiday to the Isle of Wight and had returned home the night before the inspection. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 11,12, 13, 14, 15, 16 & 17 All standards in this section were met. A range of educational opportunities and activities are provided that enable residents’ to develop their skills and interact with the local community. Family links are encouraged, maintained and promoted, where possible, giving residents’ the opportunity to develop a normal living environment built on appropriate relationships. The daily routines are tailored to the individual and promote and empower residents to make their own decisions whilst recognising the rights and property of others. The meals provided and system used encourage residents’ to take responsibility for having a balanced diet with support provided by staff as needed. EVIDENCE: Documentation and discussion with residents’ showed that the home provides access to education to promote development as required. Some residents’ attend college courses including catering and photography whilst two residents’ work at birthday bakers. There is also access to two computer terminals and two residents take responsibility for looking after the fish in the fish tank. Day centres are also used extensively as and when residents’ wish and one is providing a woodworking course. Different in-house activities take place with SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 12 the aim of providing one per day and the activity during the inspection was coffee in the park. Others available include swimming, picnics, dog walking, gardening, cooking and table tennis in the back garden. The home has also purchased a pool table that will be sited in the ground floor area. Staff are attending a life skill development course. Community links are also promoted by use of available local social amenities such as the cinema, pubs, shops, cafes and restaurants. Summer barbecues also take place. Family links are maintained and residents’ are supported and encouraged to reconnect if they wish. The level of contact varied depending on the wishes of the residents’ and their families. Daily routines are focused on the residents’ needs rather than the other way around and house rules promote respect for others and their property and health and safety. These are contained in the residents’ guide. The home provides a self-service breakfast and if residents’ wish a cooked one, they tell staff the night before and ingredients are supplied. There is a light lunch and the main meal is in the evening as many residents are out during the day. The aim was to promote this as a time for social interaction although this hasn’t had a large take up. Residents’ who wish cook for themselves and some have take-aways. Some prefer purchasing meal tickets, as they are more comfortable with this. The system is geared to promote self-money management. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 18, 19 & 20 Standards eighteen and twenty were met. Standard nineteen was not met. Personal support is not provided. Residents are encouraged and supported to take responsibility for their own personal support and to access communitybased health care to promote life skill development. Residents’ take responsibility for self-medication as appropriate, otherwise it is administered to safeguard their health and safety. EVIDENCE: Personal care is not provided although personal hygiene is monitored and staff provide prompts and support when necessary. All residents’ are registered with GPs at one of two practices and they have full access to community based health care services. There was no evidence on file that the annual health checks had taken place. The medication administration records for all residents including those who are self-medicating were inspected and no gaps in the recording were found. These records are checked on a daily basis and there was a requirement made, at the last inspection regarding this, that has now been met. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 22 & 23 These standards were not met. The complaints records were not complete and therefore it was not possible to identify if residents’ complaints are properly investigated and it was unclear if all staff had received adult protection training meaning residents’ could be put at risk. EVIDENCE: The home has a complaints policy and procedure; contained in the residents’ handbook and those spoken with were clear about how to make a complaint. The complaints records were incomplete and the last entry on 30th October 2004 did not contain details of action taken and if resolved. There is a comprehensive adult protection policy and procedure. The Care Manager had recently come to post and was not sure if all staff had received adult protection training. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 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 standard(s) 24 & 30 Standard twenty-four was met. Standard thirty was not met. The home provides a comfortable environment that meets its stated purpose. The health and safety risk assessments were not up to date and could put residents’ at risk. EVIDENCE: The home has a warm, comfortable atmosphere that the residents said they liked and which meets its stated purpose. This was confirmed by a building tour. In particular it had a well laid out, colourful garden that has a number of secluded areas for seclusion and privacy. The home was clean, tidy and odour free although the health and safety risk assessments were out of review date. Fridge and freezer temperatures are checked and recorded daily. All food was appropriately stored. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This section was not inspected. EVIDENCE: SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Standards thirty-nine and forty-two were not met. The quality assurance system did not pick up that the health and safety risk assessments were not up to date and this could endanger residents’ and staff. EVIDENCE: The organisation has a comprehensive quality assurance system with regular monthly provider visits taking place although these did not pick up that the health and safety risk assessments were not up to date. SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 18 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 2 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SHIRLAND ROAD, 93-95 Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 19 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. 2. Standard 2 2 Regulation 12 (1) (a) & 14 (1) (a) & (b) 12 (1) (a) & 14 (1) (a), (b) & (2) 12 (1) (a) & 15 (2) (b) 12 (1) (a) & 13 (4) Requirement Referral forms must be received from placing authorities. Resettlement plans must be received from placing authorities. Progress notes must record and reflect real progress made. Timescale for action 24/06/05 24/06/05 3. 4. 6 9 24/08/05 24/10/05 5. 6. 7. 8. 9, 30, 42 19 22 23 9. 39 Individual risk assessments must be reviewed and contain more indepth information focused on the resident. 12 (1) (a) The health and safety risk & 13 (4) assessments must be updated and reviewed within timescale. 12 (1) (a) Annual health checks must be & (b) carried out with the residents consent. 22 (3) Any complaints must be fully documented including action taken and outcome. 18 (1) (c) The home must establish if all (i) staff have received adult protection training and provide training for any who have not. 12 (1) (a) The quality assurance system & 21 (a) & must pick up any failure to meet (b) standards. G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc 07/08/05 24/06/05 24/06/05 24/10/05 24/06/05 SHIRLAND ROAD, 93-95 Version 1.40 Page 20 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 Good Practice Recommendations SHIRLAND ROAD, 93-95 G60-G09 S10874 SHIRLAND ROAD UIV235123 240605 STAGE 4.doc Version 1.40 Page 21 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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