Inspection on 18/05/05 for Short Break Services

This inspection was carried out on 18th May 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Short Break Services 19/12/06

Short Break Services 25/04/06

Short Break Services 22/12/05

Short Break Services 14/12/04

Short Break Services 03/06/04

Short Break Services 23/12/03

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 Short Break Services 62 Green Lane Hanwell London W7 2PB Lead Inspector Gavin Thomas Unannounced 18 & 20 May 2005 at 1pm th th 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. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Short Break Services Address 62 Green Lane, Hanwell, London W7 2PB 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 8579 9558 020 8579 9592 jonesc@ealing.gov.uk London Borough of Ealing Mr Christopher Jones Care Home 10 Category(ies) of Learning Disability (10) registration, with number of places Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14th and 22nd December 2004 Brief Description of the Service: Short Break Service is a respite provision for adults with Learning Disabilities. The service is part of a resource centre, which is owned and managed by the London Borough of Ealing. The service can accommodate up to six service users on the ground floor who have complex needs. The first floor is only accessible to service users who are ambulant. Facilities include a sensory room, a computer room, adapted bathing and showering facilities on the ground floor and an enclosed rear garden. Short Break Service is situated in a cul de sac area and set back from the main road. The service is within easy access to Ealing Hospital, local ameneties and recreational facilities. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? The service has done well in recruiting to the vacant posts. There were only three staff vacancies at the time of this inspection as opposed to the 9.5 vacancies at the previous inspection. The service now has more robust quality systems in place for reviewing the quality of care, recording and monitoring staff training and development and improving the standards of the environment. The frequency of reviewing service users care plans has also improved. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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 Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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, 4 and 5 The service continues to maintain thorough assessment procedures, which are tailored in accordance with the individual needs of the service user. The service must however, confirm the outcome of assessments in writing to the service user and/or their representative. EVIDENCE: Initial assessments are carried out with prospective service users by the CTPLD (Community Team for People with Learning Disabilities). Subsequent assessments are carried out by the Registered Manager and/or Deputy Manager. Respite Support Workers accompany management on occasions as part of their learning experience. Currently, the service does not confirm in writing to the service user that having regard to the assessment, the service is suitable for the purpose of meeting their needs in respect of their health and welfare. Introductory visits are carried out in accordance with the needs of the service user. The types of visits may include tea visits and day visits. Where appropriate, transitional visits take place over the course of a year prior to prospective service users leaving children’s services. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 9 Emergency admissions are only accepted if service users have been assessed by the CTPLD. The Deputy Manager said that service users admitted to the service in an emergency must meet the admission criteria. The contract/terms and conditions between the service and the service user has now been finalised. The Registered Manager said that the contracts will now be issued to service users and/or their representatives. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 10 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 , 9 and 10 The service is making good progress towards a consistent care planning system. EVIDENCE: The Deputy Manager confirmed that care plans were in place for all service users. Care plans examined were very well written and contained specific information with regards to the service user’s needs and how these needs are met. Care planning reviews are carried out in accordance with the frequency when service users access the service. Respite Support Workers and service users are involved in care planning reviews as much as possible. The Deputy Manager said, that on occasions, reviews are combined with other services such as Day Centres. Risk assessments are now being incorporated in service users care plans. The risk assessments seen were detailed and well written. A policy on confidentiality was in place. Lockable facilities are provided for the storage of confidential records. The Deputy Manager said there were no concerns regarding confidentiality. Staff are made aware of the codes of confidentiality in their induction and appraisals. A policy on the Data Protection Act 1998 was in place. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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 The systems for service user consultation are good with a variety of evidence, which indicates, that service users’ views on leisure and social activities are both sought and acted upon. EVIDENCE: Opportunities are given to service users to pursue and maintain their hobbies and interests as much as possible whilst receiving respite care. This is reflected in service users care plans. Service users are encouraged to maintain and develop their independence. In particular, for eating, drinking and personal care tasks. Various forms of communication are used to enable service users to make informed choices and decisions. Methods of communication include facial expressions, makaton, pictures, symbols, objects of reference and verbal communication. The Inspector observed staff using combined methods of communication with service users at the time of this inspection. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 12 The Deputy Manager said that service users would be supported to continue any religion or faith during their stay at the service. Some service users do listen to spiritual music. There were no changes to the arrangements for service users continuing their day care provisions. The unit is not directly responsible for these arrangements. The unit continues to provide day respite/drop – in services mainly at weekends and during college/day centre holidays. The Deputy Manager said that the service is currently looking into transport provisions and further leisure opportunities. This was instigated as a result of an independent survey carried out with some service users. A structured programme of daily activities was not in place. Activities are arranged in accordance with the service users accessing the service at any one time. Trips and outings away from the unit are normally planned in advance. The unit has a variety of indoor resources including a computer, sensory room, tabletop games and music equipment. Some of the equipment in the sensory room was not in working order at the time of this inspection. These items were scheduled for maintenance in June 2005. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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 & 20 Personal support is offered in such a way as to promote and protect service users’ privacy, dignity and independence. The health needs of service users are well met with evidence of good multi disciplinary work taking place when required. EVIDENCE: The Inspector observed staff promoting service users privacy when assisting them with personal care tasks. The Deputy Manager said it is not always possible to provide intimate care by staff of the same gender. The unit has a higher ratio of female staff as opposed to male staff. Personal care and support needs were set out in service users care plans. Service users are encouraged and supported to be independent as much as possible. Procedures were in place for training new staff when supporting service users with personal care tasks. Two new staff who were on duty at the time of this inspection confirmed this. The Registered Manager and the Deputy Manager carried out two unannounced visits at the unit since the last inspection. The Deputy Manager said that one of the aims for these visits was to monitor consistency and continuity of care. The Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 14 Inspector examined reports for these visits. The management team is commended for implementing this system. The Deputy Manager was of the opinion that these visits were well received by staff on duty at the time. Where appropriate, service users continue to receive on going support from the Speech and Language therapist and the Physiotherapist. There were no changes to the medication policy. The storage of medication and Medication Administration Records were satisfactory. Staff are not permitted to administer rectal diazepams. This rule is set out in a policy, which is included, the general medication policy. The training in epilepsy, which was due to take place in March 2005, was not carried out. This training must be arranged for the staff team. The Deputy manager confirmed that medication training has been arranged for the current year. A system is now in place for staff to record and sign for medicines returned to families. There were no service users self-medicating at the time of this inspection. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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 standard(s) 22 & 23 The complaints process for this service is good. Complaints information is available to service users. Proper procedures were in place for ensuring a proper response to any suspicion or allegation of abuse. EVIDENCE: A complaints policy and procedure were in place. There were no changes to these documents. The Deputy Manager said that carers/relatives and significant others were aware of the unit’s complaints procedure. The record of complaints indicated that the service received one complaint since the last inspection. A simplified version of the complaints procedure is displayed in the hallway on the ground floor for the benefit of service users. The unit had received one complaint since the last inspection. This complaint was investigated locally within the unit. An adult protection policy was in place. The Deputy Manager reported that there had been no allegations or incidence of abuse since the last inspection. A copy of the Department of Health No Secrets guidance document could not be located at the time of this inspection. A copy of this document must be obtained and disseminated amongst the staff team. Staff last attended training on adult protection in 2003. Updated training on adult protection is scheduled in the current training programme. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 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 standard(s) 24, 27 & 29 & 30 The standard of the environment is continuously improving to provide service users with a more attractive and homely place to stay. This is also evidenced for achievement through a scheduled maintenance programme. EVIDENCE: A programme of routine maintenance was in place. The home was clean throughout. An offensive odour was present in one of the bathrooms on the ground floor. The Deputy Manager explained that this odour was the caused by a water leak. As a result, damp was also present on two of the walls. Maintenance work for this bathroom is scheduled to take place in June 2005. The Registered Manager confirmed that this is being addressed as a matter of urgency. The décor in some areas of the premise requires updating. These areas are as follows: Ground floor • Lounge walls. • Skirting boards, doors and doorframes. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 17 First floor • Bedrooms • Bathrooms All areas identified are included in the maintenance programme. Two bedrooms on the first floor have been redecorated since the last inspection. As a result of an independent survey carried out with some service users, the following has been identified to improve the environment. • Consultation with a gardening project to give the garden a “make over”. • Replacement carpets to be fitted on the ground floor. • Replacement furniture to be provided on the ground floor. • Consultation with service users who stay overnight about making bedrooms more homely. The service has a total of three baths, two showers and six toilets. Two baths, two showers and two toilets are situated on the first floor. Two of the four toilets on the ground floor are situated near the dining room. The shower on the first floor is now in working order after being out of use for some time. Good progress is being made in providing adapted facilities on the ground floor. A new adapted bath has been installed on the ground floor. This bath was not in use at the time of the inspection for technical reasons. Overhead track hoists are now provided in both bathrooms on the ground floor. Further adaptations under consideration include overhead tracking facilities in three of the bedrooms on the ground floor and a new changing bed for one of the bathrooms on the ground floor. Laundry facilities are sited away from the food preparation area. COSHH (Control of Substances Hazardous to Health) procedures were in place. There was no evidence to confirm that services and facilities and facilities comply with the Water Supply (Water Fittings) Regulations 1999. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 18 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) 31, 35 & 36 The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. The planning for staff training, one to one supervisions and appraisals is more robust. EVIDENCE: Two staff confirmed that they were in receipt of a job description. Two new staff on duty confirmed that they were being fully supported by the service to understand service users needs and how these needs are met. The Inspector observed all staff including the two new staff, interacting pleasantly with service users. All staff must be issued with the standards of conduct and practice set by the General Social Care Council. A training and development programme for the period 2005 – 2006 was in place. The training programme includes mandatory training in Fire safety, Food hygiene, moving and handling and First Aid. Evidence of training undertaken is retained on individual staff files. Staff training needs are identified in one to one sessions and annual appraisals. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 19 Induction and foundation training programmes were in place for new staff. This was included in the Learning Disability Award Framework – accredited training. The two new staff on duty confirmed that they were in the process of completing their induction. The numbers of staff on duty at the time of this inspection reflected this. A programme for one to one supervisions with staff was in place. The London Borough of Ealing has also produced a standard format for annual appraisals. One member of staff was in one to one supervision at the time of this inspection. Another member of staff was also in a meeting with their NVQ Assessor. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 20 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, 40 & 42 The service now has systems in place to regularly review aspects of its performance through a good programme of self – review and consultations, which include seeking the views of service users, staff and relatives. Records for the monitoring of health and safety procedures have improved. EVIDENCE: Good progress was being made towards quality assurance and monitoring systems. The Registered Manager and Deputy Manager have undertaken unannounced visits to the service at weekends. Monthly unannounced visits are still carried out by the Service Manager as required under Regulation 26 of the Care Homes Regulations 2001. Copies of reports for these visits are supplied to the CSCI. The Ealing Partnership Group carried out an independent survey with nine of the service users. The service has acted on the feedback given by service users. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 21 Carers (parents/relatives) continue to meet at Short Break Service for a monthly coffee morning. The Registered Manager has devised a detailed self monitoring system which includes a review of the quality of care, seeking the views of the service from staff and significant others, consultation with the Quality assurance Framework (Partnership Board) and a review of all policies and procedures. Policies and procedures have been revised, updated and signed by the Registered Manager. Detailed health and safety risk assessments were in place. These included a fire risk assessment, assessments of direct work activities, equipment and the premises. According to records examined, the most recent fire drill was carried out in October 2004. The frequency of fire drills must be increased. Hot water temperatures are tested routinely. Records examined confirmed this. Action was being taken to address the temperature of water storage. A Legionella assessment was due to be carried out on 25th May 2005. Records examined indicated that approved contractors test fire appliances, gas and electrical facilities routinely. Records seen confirmed that thermostatic control valves are fitted to all bathing and showering facilities. Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 22 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 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 3 x 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x x Standard No 31 32 33 34 35 36 Score 3 x x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Short Break Services Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 3 x 2 x G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 23 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 2 Regulation 14-(1)(d) Requirement The service must confirm in writing to the service user that having regard to the assessment, the service is suitable for the purpose of meeting their needs in respect of their health and welfare. Training on epilepsy must be arranged for the staff team. A copy of the Department of Health No Secrets guidance document must be obtained and disseminated amongst the staff team. Evidence must be obtained to confirm that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. ( Timescale of 31/3/05 not met). All staff must be issued with the standards of conduct and practice set by the General Social Care Council. The frequency of fire drills must be increased. Timescale for action 31/7/05 2. 3. 20 23 18-(1)(c ) (i) 13(6) 31/7/05 31/7/05 4. 30 23(2)(c ) 30/6/05 5. 35 18-(1)(a) 31/7/05 6. 42 23(4)(e) 30/6/05 Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 24 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 Short Break Services G61-G10 s32384 Shortbreak v214217 180505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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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