Inspection on 22/12/05 for Short Break Services

This inspection was carried out on 22nd December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Short Break Services 19/12/06

Short Break Services 25/04/06

Short Break Services 18/05/05

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 Mr Gavin Thomas Unannounced Inspection 22nd December 2005 3:00 Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Short Break Services Address 62 Green Lane Hanwell London W7 2PB 020 8579 9558 020 8579 9592 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) London Borough of Ealing Mr Christopher Jones Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 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 amenities and recreational facilities. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 2.45hrs. The Inspector met with the Registered Manager and one Deputy Manager. The Inspector also spoke with service users and staff on duty including the cook. Prior to this inspection, the Commission for Social Care Inspection carried out an additional visit at this service in October 2005. This visit was in response to concerns raised by two people regarding staff conduct and practice. A separate report was issued for this visit. The requirements for the additional visit and those from the previous inspection in May 2005 were followed up on this visit. The Inspector carried out a tour of the ground floor with the Deputy Manager. Service users were relaxing in the lounge and in the seating area in the hallway before having their evening meal. One service user told the Inspector they were well and continued to enjoy their visits to the home. What the service does well: What has improved since the last inspection? Out of the six requirements made at the previous inspection in May 2005, five requirements were met and one was not met. The presentation of the lounge has improved since the last inspection. This room is much more presentable and homely since it was redecorated. The home has recruited a second Deputy Manager, which will strengthen the management team and provide additional resources for meeting the demands of this service. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 DS0000032384.V261316.R01.S.doc Version 5.0 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 Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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): 2 The admission criteria for this service is robust which includes a thorough assessment procedure. EVIDENCE: There have been no changes to the admissions criteria for this establishment. 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 these occasions as part of their learning experience. Service users and/or their relatives are now informed in writing of the outcome of their assessment and if the service is suitable in meeting their assessed needs. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 The home is still required to ensure that staff are more consistent when implementing care plans. The quality of one care plan examined was very well written. Good progress has been made with regards to the provision of advocacy services. EVIDENCE: The Registered Manager was in the process of carrying out an audit on all care plans to ensure that service users’ care needs are recorded in sufficient detail and staff are consistent in their approach. This task had not been completed within the timescale set at the additional visit in October 2005. The Registered Manager explained that priority was being given to service users who have complex health and care needs and who use the service more often than others. This requirement is restated and an audit must be achieved within the revised timescale set. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 10 The care plan examined, gave detailed information about the service user’s needs and how staff were required to support the service user for specific tasks. The procedural guidance was clearly set out. The Registered Manager has devised an action plan to ensure that care is given to service users’ in accordance with needs identified in their care plans. This action plan involves staff reading and signing amended care plans, discussions in staff meetings, monitoring the implementation of care plans and reviewing care plans regularly. This requirement has not been met within the timescale set at the additional visit in October 2005. The Registered Manager explained that this requirement would be implemented once the care plan audit has been completed. This requirement is restated and must be achieved within the revised timescale set. The Registered Manager confirmed that where possible, service users would be supported in decision-making processes. Various forms of communication systems are used with individual service users. An advocacy project has been introduced since the last inspection. This project is coordinated by a representative from Mencap. The project is funded by the Learning Disability Development Fund. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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): 15, 16 & 17 The systems for consulting with service users’ families and significant others are improving. The meals served in this home were judged to be good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The Registered Manager said the home maintains good relationships with service users and their relatives. The home was in the process of setting up family meetings with a view to be launched in 2006. These meetings will be chaired by the Registered Manager and would give relatives an opportunity to learn more about the provisions of service and to discuss their views and opinions about the service. Currently, the home organises two major social events. One in the summer and one at Christmas. Keys to bedrooms are issued to service users in accordance with their capabilities. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 12 Service users are supported and encouraged to maintain their independence Service users independence levels are identified at initial assessments and monitored periodically. Service users can choose when to be alone or in the company of others. This was observed at the time of this inspection. Staffing levels also reflected the needs of the seven service users on respite care at the time of this inspection. The Inspector observed staff speaking with service users in a calm and pleasant manner. Although service users are not engaged in domestic tasks such as cooking and cleaning, they are supported to maintain and develop other skills such as eating, drinking and dressing. Where appropriate, details for supporting service users are set out in their care plans. Only one service user was on a Peg Feed at the time of this inspection. Only trained staff are permitted to set up the Peg Feed. The cook confirmed that liquidised or softened foods are done so separately. Specialist diets are provided in accordance with service users health or cultural requirements or personal preferences as advised by families. Adapted cutlery or crockery are provided by families or the home. When necessary service users fluid/food intake is monitored and recorded for specific reasons such as serious weight loss or weight gain. The Registered Manager confirmed that any concerns regarding service users’ diet are communicated with service users’ families. Foods are purchased locally. Where possible, service users are involved in food shopping. Meals are prepared freshly on a daily basis. The main meal of the day is served in the evenings from Monday to Friday and at lunch times on weekends. Where possible, service users are involved in menu planning. A record of food served was in place. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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): 19 The health needs of service users are well met with good examples of multi disciplinary work taking place when required. EVIDENCE: Service users health needs are recorded on their care plans. In addition to having a learning disability, the majority of service users have associated health needs including: • Physical disabilities. • Epilepsy. • Asthma. • Limited/no verbal communication skills. All service users are registered with a family GP. Service users’ families are responsible for arranging primary health care treatments. The Registered Manager explained that the home would support service users and their families with hospital appointments if required. Service users health needs are reviewed at statutory reviews and at other times when necessary. Health care reviews are also updated for service users who do not use the service frequently. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 14 The Inspector observed one member of staff using the care plan with the service user who had complex health needs. This was judged to be very good practice. The Registered Manager was of the opinion that service users health needs were being met during their periods of respite care. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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): 23 Shortfalls in staff conduct with regards to maintaining acceptable standards of practice were being addressed with the staff team. EVIDENCE: Adult protection policies and procedures were in place. Additional visits were carried out by the Commission for Social Care Inspection on 5th & 18th October in response to concerns raised by two people. Some of these concerns did relate to staff conduct and care practice. The London Borough of Ealing was still in the process of investigating these allegations. As a result of these concerns raised. The Registered Manager was required to arrange updated training in adult protection for all staff, ensure that staff conduct themselves so as to ensure that the health and welfare of service users are met appropriately. The Registered Manager confirmed that adult protection training has been arranged for January and February 2006. The Registered Manager also confirmed that staff were reissued the London Borough of Ealing’s Code of Conduct and Behavioural Standards in November 2005. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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): 28 & 30 Recent work carried out on the ground floor has significantly improved the appearance of the lounge creating a more pleasant and homely environment. EVIDENCE: Areas of the home inspected were clean and free from mal odours. The home has two lounges. One on the ground floor and one on the first floor. The lounge on the ground floor had been redecorated since the last inspection. This room is much more presentable now. The new colour gives the room a sense of brightness and calm. The curtains have also been replaced in this lounge. Seating is provided in the hallway. This was being used by one service who chose to be away from other people but with staff supervision. Smoking is not permitted anywhere in the home. Smoking is permitted on the balcony on the first floor or outside of the main building. These rules apply to both staff and service users. It is very rare that this home has service users who smoke. Private rooms are provided on request for visitors. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 17 Staff are provided with adequate facilities for the storage of personal possessions and sleeping facilities when sleeping in. A programme of routine maintenance was in place. Progress towards the implementation of this programme will be monitored future inspections. Hand washing facilities are sited prominently throughout the home. The laundry is situated on the ground floor, away from the kitchen and dining room. Policies and procedures in infection control were in place. There was no evidence to confirm that services and facilities comply with the Water Supply (Water Fittings) Regulation 1999. The Registered Manager reported that the London Borough of Ealing was dealing with this matter. This requirement is restated from the previous two inspections and must be met within this revised timescale set. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 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 & 36 An action plan was in place to review staff conduct and performance and to address any shortfalls in teamwork. The Commission for Social Care Inspection will monitor the implementation of this action plan. EVIDENCE: The home had a total of eleven care staff. One staff had been redeployed to another service on a short-term basis. There were four vacancies. No date had been set to recruit to these posts. Agency staff were being used to cover vacant posts. A second Deputy Manager had been appointed since the last inspection. The Deputy Manager was still undergoing an induction at the time of this inspection. Six staff had an NVQ level 3 in care. Two staff were registered to undertake this course and two staff were not registered to undertake NVQ training. The Registered Manager was of the opinion that there was a good range of skills and experience within the staff team. However, in light of concerns raised by two people in October 2005, the Registered Manager was required to address the shortfalls relating to staff conduct, professional development and teamwork. This requirement has not been fully implemented and has therefore been restated and must be met within the revised timescale set. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 19 Recruitment policies and procedures were in place. The Registered Manager explained that evidence of recruitment checks are not held in the home but retained by the London Borough of Ealing. Therefore these records were not available for inspection purposes. Currently, the home does not obtain copies of recruitment records as required under Schedule 2 of the Care Homes Regulations for agency staff who work regular at the home. Although the Registered Manager explained that an independent body appointed by the London Borough of Ealing now allocates agency staff, copies of recruitment checks must be obtained and made available for inspection purposes. The Registered Manager confirmed that Criminal Records Bureau checks (CRB) had been carried out on all staff at enhanced level. As a result of the additional visit carried out in October 2005, the Registered Manager was required to implement a system whereby all staff receive regular one to one supervision. In accordance with standard 36.4 of the National Minimum Standards for Care Homes for Adults (18-65), these meetings should be done at least six times a year. The Registered Manager was also required to implement a system to ensure that agency staff received supervision if they worked regular shifts. The Registered Manager has set out an action plan to implement a programme of supervisions. This was partially met for permanent staff and not met for agency staff. This requirement has been restated and all staff including agency staff working regular shifts must receive at least one supervision meeting within the revised timescale set. The implementation of the programme for supervisions for the rest of the year will be monitored at future inspections. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 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 & 38 The Registered Manager has a good understanding of the areas in which the home needs to improve. Planning was in place, demonstrating how these improvements were going to be resourced and managed. EVIDENCE: The Registered Manager has been in his current post for six years. The Registered Manager has worked in various settings and services for children and adults with learning disabilities for the past seventeen years out of which fifteen have been at management level. The Registered Manager was working towards the Registered Managers Award (RMA). Training undertaken by the Registered Manager within the last year has been linked to this award, Person Centred Planning and management training. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 21 As a result of the additional visit in October 2005, the Registered Manager was required to implement systems for enabling staff, service users and families to voice concerns and affect the way the service is delivered. The Registered Manager had devised an action plan to meet this requirement, which included: • Consultation processes with staff (regular team meetings, supervisions, handovers and the application of relevant policies with the staff team such as whistle blowing). • On going meetings with families. • Introduction of feedback forms for overnight stays. • Consultation with service users. These strategies have not been fully implemented. However, dates have been identified for initial meetings. This requirement is restated and must be fully implemented within the revised timescale set. Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 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 3 x x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x 3 x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 2 x 2 x 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Short Break Services Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 2 x x x x x DS0000032384.V261316.R01.S.doc Version 5.0 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 YA6 Regulation 12(1)(a) Requirement The Registered Manager must complete an audit of all care plans to ensure all care needs are recorded in sufficient detail. (Timescale of 25/11/05 Not Met). The Registered Manager must ensure that all care is given in accordance with needs identified with care plans. (Timescale of 25/11/05 Not met). The Registered Manager must ensure that all staff have the necessary training in adult protection to ensure that they understand the importance of challenging poor practice. (Timescale of 25/11/05 Not met). Evidence must be obtained to confirm that services and facilities comply with the Water Supply (Water Fittings) Regulations 1999. (Timescale of 30/6/05 not met). The Registered Manager must ensure that staff conduct themselves so as to ensure the health and welfare of service users. (Timescale of 25/11/05 DS0000032384.V261316.R01.S.doc Timescale for action 31/03/06 2 YA6 12(1)(a) 31/03/06 3 YA23 YA22 13(6) 28/02/06 4. YA30 23(2)(c ) 28/02/06 5 YA32 12(1)(a) 28/02/06 Short Break Services Version 5.0 Page 24 Not met). 6 7 YA34 YA36 19 Schedule 2 18(2)(a) Evidence of recruitment checks must be obtained for agency staff. All staff must receive regular supervision with their line manager. (Timescale of 25/11/05 Not met). The Registered Manager has strategies in place for enabling staff, service users and families to voice concerns and to affect the way the service is delivered. (Timescale of 25/11/05 Not met). 28/02/06 28/02/06 8 YA38 12(1)(a) 28/02/06 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 Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection West London Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Short Break Services DS0000032384.V261316.R01.S.doc Version 5.0 Page 26 - 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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