Inspection on 09/12/05 for Spring Grove Road, 231

This inspection was carried out on 9th 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spring Grove Road, 231 20/07/06

Spring Grove Road, 231 24/05/05

Spring Grove Road, 231 13/09/04

Spring Grove Road, 231 27/04/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Spring Grove Road, 231 Isleworth Middlesex TW7 4AF Lead Inspector Robert Bond Unannounced Inspection 10:00 9 December 2005 th Spring Grove Road, 231 DS0000022906.V260537.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 Spring Grove Road, 231 DS0000022906.V260537.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. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Spring Grove Road, 231 Address Isleworth Middlesex TW7 4AF 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) 0208 758 2966 Milbury Care Services Limited Teresa Franze Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one named service user who is over the age of 65 years old as agreed by the Commission of Social Care Inspection (CSCI) on the 27th July 2004. The service user may remain resident until such time when the home is unable to meet the service user`s assessed needs and care plan. The establishment must inform CSCI when the service user no longer resides at the home. Home registered from a Three Bedded Unit to a Two Bedded Unit as agreed by the Commission for Social Care Inspection, on the 31st December 2004. 24th May 2005 2. Date of last inspection Brief Description of the Service: 231 Spring Grove Road is a home for two service users with learning disabilities, one of whom is over 65 years old. It is a detached three bedroomed house, situated on a busy road in Isleworth, and close to public transport to Hounslow Town Centre and Brentford. There are local shops within walking distance and the day centre and college are also close by. The home is owned and managed by Milbury Care Services. The communal areas consist of a lounge, with a separate kitchen/dining room. The office, laundry room and staff toilet are located in an outbuilding located in the small back garden. There is a bathroom on the first floor, with a bath and separate shower cubicle, and a separate toilet. The third bedroom is used as the staff sleeping in room. The neighbouring house, at 233 Spring Grove Road, is a home for three service users and the Registered Manager is registered for both homes. The Deputy Managers post also covers both homes. There is a separate Senior Support Worker and a team of Support Workers for each house. They provide support with personal care, practical tasks, leisure and social activities. There are two staff on duty at all times, with one sleeping in staff at night. Both service users use the Milbury Day Centre and West Thames College, which are local. There is a house car available. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The CSCI currently undertakes two unannounced inspections of all care homes per year, during which the key standards of the National Minimum Standards (NMS) are assessed. This second inspection of the year concentrated upon assessing the extent of the care home’s compliance with the requirements and recommendations that were made following the last inspection. The Inspector met the Registered Manager, two support workers and one service user. He toured the home and examined various records and policies. He was on site for three hours. The Inspector assessed 12 of the NMS, and found that 2 were met, 9 were not fully met, and 1 was not met. He made 17 requirements, of which 3 are restated from the last inspection having not been achieved within the previous timescales set, and he made 2 recommendations. What the service does well: What has improved since the last inspection? The shower is now in working order. Thermometers have been purchased for monitoring the temperatures of fridge and freezer. The setting of the refrigerator has been adjusted so that it operates at the correct temperature. Staff have undertaken additional core and refresher training and infection control training. Service users’ health records have been improved so that appointments can be more easily recorded and monitored. New staff will receive medication training that is competency based. Spring Grove Road, 231 DS0000022906.V260537.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. Spring Grove Road, 231 DS0000022906.V260537.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 Spring Grove Road, 231 DS0000022906.V260537.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): 5 The outcome is not met. EVIDENCE: The Registered Manager reported that although new contracts have been prepared, and agreed with the purchasers of the home’s services, the contracts have not yet been issued to service users as they apparently have not yet been approved by the CSCI’s Provider Relationship Manager. Requirement 1 is therefore restated. Spring Grove Road, 231 DS0000022906.V260537.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): As outcomes 6 to 10 were fully met at the last inspection, these standards were not assessed again at this inspection. EVIDENCE: Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 10 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): As outcomes 11, 12, 13, 15 and 17 were fully met at the last inspection, these standards were not assessed again at this inspection. EVIDENCE: Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 11 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 and 20 The outcomes for NMS 18 and 19 are fully met. The outcome for NMS20 is only partly met for the reasons stated below. EVIDENCE: NMS18: The Inspector talked to the one service user who was present during the inspection. She indicated that she was happy at the home. The Inspector briefly examined her care file, which was well maintained. NMS19: The Inspector examined both service users’ health records and noted that the system of recording appointments was much improved. NMS20: The Inspector examined the home’s medication storage facilities and medication records. Drugs are stored in special medication cabinet in the office, but the cabinet is not securely fixed to the wall as required to keep it from being stolen, and to prevent it falling onto a member of staff. Requirement 2. The Inspector found that the MAR sheet for one service user did not show its start date nor the finish date, hence it was not obvious which month’s medication administration was being recorded. Requirement 3. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 12 The MAR sheet in question had not been marked to show that Cefradine had been administered that morning. Requirement 4. The container of Cefradine had been marked by the pharmacist as containing 20 tablets, but the MAR records and unused tablets only accounted for 14 tablets. The Registered Manager and a support worker confirmed that only 14 tablets have ever been received. Hence the pharmacist appears to have made a error in filling out a prescription with the quantity of tablets incorrectly marked on the packing. The home should have spotted the error when entering the medication into their medication received book. Requirement 5. The Inspector checked the home’s medication returned book and found only the most recent return was recorded, and this had been signed by the pharmacist but not by a representative of the home. Requirement 6. The home must always retain a copy of the medication return sheet, signed by both parties. Requirement 7. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 13 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 The outcome is not fully met for the reasons stated below. EVIDENCE: The Inspector asked to see the home’s policy on restraint of service users. The Registered Manager responded that all staff were trained in ‘non-violent crisis intervention’ but no Milbury policy on this could be located. Requirement 8. The Inspector asked to see records of expenditure of service users’ own money held by the home. These demonstrated that sometimes service users are asked to pay for the purchase of items of bedding. The Registered Manager reported that sometimes the home pays, sometimes the service user, sometimes a relative, and that it was Milbury policy to ask relatives to contribute towards the cost of new bedding. The Inspector examined the home’s written policy on management of service users money and financial affairs’, which does list appropriate items that may be bought with service users’ money, but bedding is not one of them. Milbury need therefore to clarify their policy, as it is applied at 231 Spring Grove Road, and train the staff at that home in the appropriate application of the policy. Requirement 9. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 14 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, 26, and30 The outcomes are not fully met for the reasons stated below EVIDENCE: The Inspector toured the home in the company of the Registered Manager. NMS24: The Inspector noted a number of trailing wires, such as those leading to the Christmas tree lights in the living room, which present a trip hazard to service users and staff. See NMS 42 (Health and Safety) for the appropriate requirement. The home however is domestic in style, and homely but is in need of redecoration in places, for example the bathroom tiles mentioned in the last inspection report. Requirement 11 NMS26: The Inspector noted that one bedroom does not have a wash-hand basin, and that neither bedroom contains a lockable space for service users’ personal valuables, and neither room contained a table to sit at. These are all required by NMS 26.2 ‘unless agreed otherwise in the service user’s individual plan, or being identified as in their best interests’ not to provide it. The Inspector believes that as a general rule these items should always be provided unless there is a very good reason not to, and the service user or their representative must sign their agreement that the items will not be Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 15 provided, and why that is. The Registered Manager must take action along these lines. Requirement 10. NMS30: The home is generally clean and hygienic but extractor fans and lampshades were seen to be dirty. A planned maintenance system should pick up ‘deep cleaning’ issues such as these. Other examples of poor maintenance that the Inspector observed were the freezer in need of being defrosted, and a foot having broken off the bottom of the fridge. See Requirements 11 and 12. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 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 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): 34 and 35 The outcomes are not fully met for the reasons stated below EVIDENCE: NMS34: The Inspector examined the staff recruitment files for two members of staff. One was satisfactory, but the Inspector noted on the other that the applicant had not fully completed her health questionnaire and yet that did not seem to have been followed up by anyone, and secondly only one reference was on file. The Registered Manager said this was because it had been returned to the referee, with a request that the reference be supplied on headed paper. In this event, the original reference must be kept, and a photocopy returned to the originator. The home does not have a photocopier, see Recommendation1 and Requirement 13. NMS35: The Inspector examined staff training records. These indicated which staff members had undertaken specific training, such as Infection Control training, but not the date that the training had been provided. NMS 35.5 requires that each member of staff have an individual training and development assessment and profile. This document will show a member of staff’s assessed training needs, as well as training already undertaken, and the date it was undertaken. Such a record is best produced on a computer. The home does not have a computer, see Recommendation 2 and Requirement 14. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 17 Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 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): 39 and 42 The outcomes are not fully met for the reasons stated below. EVIDENCE: NMS39: The Inspector examined the internal audit records of the home. He found that requirement 5 from the last inspection had not been met as no summary had been prepared following receipt of service users’ questionnaires to assess the quality of life in the home, where this has improved, and where improvements can be made. See new Requirement 15. NMS42: A trip hazard is identified in NMS 24. In addition, in three areas of the home, doors were found that were stiff to open since they scraped the floor, and require to be ‘eased’. The issue is that staff may injure themselves whilst struggling to open or close one of these doors. Most worrying was that a chemical toilet cleaner had been left in the toilet and not locked away in the COSHH cupboard. This was corrected at the time but action must be taken to deal with all other Health and Safety concerns mentioned here. Requirement Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 19 16. Staff must be trained in spotting, correcting or reporting Health and Safety concerns. Requirement 17. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 1 Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x x x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 2 2 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Spring Grove Road, 231 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000022906.V260537.R01.S.doc Version 5.0 Page 21 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 YA5 Regulation 5(1) (b) Requirement The contract/statement of terms and conditions must be completed fully for each service user and agreed with them or their representatives. THIS IS RESTATED FROM THE PREVIOUS FOUR INSPECTIONS. (previous timescale of 31/07/05 not met) The medication cabinet must be secured to the wall The MAR sheets must always record the sheet’s start and finish dates The MAR sheets must always be initialled to record medication administered, straight away after the administration When medication is received into the home, its name, strength and quantity must be checked and recorded. Whenever medication is returned to the pharmacist, a representative of the home must sign the record sheet. The home must always retain a copy of the returned medication sheet, signed by the pharmacist and a representative of the home. DS0000022906.V260537.R01.S.doc Timescale for action 01/02/06 2 3 4 YA20YA42 YA20 YA20 13 (2) 13 (2) 13 (2) 01/01/06 01/01/06 01/01/06 5 YA20 13 (2) 01/01/06 6 YA20 13 (2) 01/01/06 7 YA20 13 (2) 01/01/06 Spring Grove Road, 231 Version 5.0 Page 22 8 9 YA23 YA23 13 (7&8) 13 (6) 10 YA26 16(2)(c) 23(2)(j) 23 (2) (d) 23 (2) (b&c) 19 &Sch 2 11 12 13 YA30YA24 YA30 YA34 14 15 YA41YA35 YA39 17(2) Sch 4(6f) 24 16 A42 13 (4) (c) A restraint policy is required that includes reference to ‘non-violent crisis intervention’. Staff must be trained to operate within the Provider’s policy on ‘managing service users’ money’ in order to minimise any potential for allegations of financial abuse. The Registered Person must provided adequate furniture and wash-hand basins to promote independence of service users. All parts of the home must be kept clean and reasonably decorated. The premises inside and out, and all equipment must be kept in good working order. Checks on the fitness of workers must include two references, one from the last employer, and that s/he is physically and mentally fit. The information required to be obtained for the recruitment and employment of staff must be verified, complete and available for inspection. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. (previous timescale of 31/7/05 not met). Adequate training records must be kept A report from the audit of the home that involves service user questionnaires is required that identifies outcomes and how improvements can be made. This needs to be available when completed to service users, their representatives and the CSCI. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. (PREVIOUS TIMESCALE OF 31/7/05 NOT MET) All health and safety concerns identified in the body of the report must be dealt with DS0000022906.V260537.R01.S.doc 01/02/06 01/02/06 01/03/06 01/03/06 01/03/06 01/02/06 01/02/06 01/02/06 01/01/06 Spring Grove Road, 231 Version 5.0 Page 23 17 YA42 18 (1) (c) All staff must be adequately trained in all appropriate health and safety matters 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA34 YA35 Good Practice Recommendations That a photocopier is provided for use by the care home. That a computer is purchased, and installed in such a way that service users and staff can use it securely. Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 24 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 Spring Grove Road, 231 DS0000022906.V260537.R01.S.doc Version 5.0 Page 25 - 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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