Inspection on 24/10/06 for St Raphaels

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Raphaels 17/10/08

St Raphaels 02/06/06

St Raphaels 24/10/05

St Raphaels 05/04/05

St Raphaels 15/12/04

St Raphaels 14/06/04

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 St Raphaels The Butts Brentford Middlesex TW8 8BQ Lead Inspector Ms Jean Bovell Key Unannounced Inspection 24th October 2006 11:30 St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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 St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Raphaels Address The Butts Brentford Middlesex TW8 8BQ 0208 560 3745 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) The Francis Taylor Foundation Sister Clare Casey Care Home 19 Category(ies) of Learning disability (19) registration, with number of places St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User aged over 65 not by reason of old age Date of last inspection 2nd June 2006 Brief Description of the Service: St Raphaels is situated in a quiet residential area in Brentford. It is close to the Brentford High Street and within easy reach of Hounslow and Chiswick town centres. There are good public transport links close by. The home is one of two on the site, managed by the Frances Taylor Foundation. The other home, Maryville, is for older people and is inspected separately. There is also, on the site, a convent and six flats for Sisters of the Order and staff. The large, well maintained gardens are available to all service users within the complex. There is a Roman Catholic church incorporated in Maryville. The establishment is for nineteen service users with learning disabilities and is arranged in three units. Two units are situated over two floors in Fatima House. St Raphaels is a large house, which is detached from Fatima House. St Raphaels has an enclosed courtyard garden. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11:30am and 2:30pm on 24th October 2006. The Registered Manager and a total of four care support workers and eight service users were present within both units at the home. The Inspector was informed by the Registered Manager that eleven service users attending the day centre. During the course of the inspection, records, documents, policies and procedures were viewed. A tour of building was undertaken and observations were made. Four members of the care support staff team and eight service users were spoken with. The requirements that were made at the last inspection and all outstanding Standards were examined. What the service does well: The service users were appropriately dressed and appeared well cared for and content within their environment. They were observed being closely supervised or engaged in separate activities with care support workers. All records viewed were satisfactory and indicated that the safety and welfare of the service were being safeguarded. In particular service users received opportunities for personal development and their specific cultural/ religious, social and emotional needs were being met. Care support workers were observed being competent and attentive in responding to the needs of the service users and related with them in a friendly and respectful manner. Overall, the home was found to be clean, hygienic and well maintained. The atmosphere was bright, airy, calm and pleasant. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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 St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The service users’ guide was not available for inspection. A requirement relating to needs assessments under Standard 2 at the last inspection has been met. Prospective service users and their relatives are invited to the home during the initial assessment process. Signed contracts/statement of terms and conditions confirming the home’s capacity to meet specific assessed needs are in place. EVIDENCE: The home’s statement of purpose was in place and contained the required information. However, the service users’ guide was not available for viewing at the time of the inspection. It was evidenced on the file of a service user who was recently admitted to the home that a needs led assessment had been submitted to the home by the placing authority at the point of referral. This complied with a requirement under Standard 2 at the last inspection. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 9 The records were reflective of prospective service users and their relatives being invited to the home prior to admission. These records also indicated that written confirmation about specific assessed needs would be met at the home and were included within appropriately signed contracts/statement of terms and conditions. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Requirements under Standards 6 and 9 at the last inspection relating to daily logs, care plans and risk assessments have been complied with. Service users are supported in making decisions in relation to daily routines and aspects of life within the home. The confidences of the service users are being respected. EVIDENCE: In compliance with requirements under Standard 6 at the inspection, separate daily records relating to the service users were being maintained and a detailed care plan regarding a newly placed service user was in place. The Registered Manager confirmed that service users were encouraged to make decisions regarding colour schemes and curtains when individual bedrooms and communal areas within the home were being decorated. They St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 11 were also able to make decisions in relation to meals, activities, clothing and when they got up in the morning and retired at night. Service users were observed moving freely and comfortably around the home and participated in activities of their choice at the time of the inspection. Personal choices were also reflected in their individual bedrooms. Risk assessments in relation to specific activities identified within care plans had been undertaken and met a requirement under Standard 9 at the last inspection. The home’s policy on confidentiality and disclosure of information were in place. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 12 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): 11. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Adequate opportunities for personal development are being provided at the home. EVIDENCE: The Registered Manager reported that none of the service users were in employment or attended college. However, they attended the day centre and participated in yoga and dance classes that were held at the home each week. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 20. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Requirements under Standards 18 and 20 at the last inspection have been met. These related to care plans, controlled drugs and medication records. A requirement under Standard 20 at the last inspection in relation to bottled medication has not been complied with. EVIDENCE: A number of care plans were viewed at random and it was evidenced that separate personal care needs were identified and clearly detailed. This complied with a requirement under Standard 18 at the last inspection. Records of medication received at the home were in place and recordings of controlled drugs had been completed in ink. This met with requirements under Standard 20 at the last inspection. A requirement under Standard 20 at the last inspection remained outstanding. This related to dates of opening being recorded on bottled medication. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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 the following standard(s): 22. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place. EVIDENCE: The complaints procedure was clear and concise. The Registered Manager confirmed that no complaints had been made to the home following the last inspection. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 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 the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. A requirement under Standard 24 at the last inspection has been met and related to fixtures on bedroom doors. The service users bedrooms are personalised and reflect separate choices and interests. The bathroom and toilet facilities are sufficient for meeting the needs of the service users and the communal areas are suitable for shared or individual activity. Appropriate specialist equipment for assisting the service users is in place. The home is clean, hygienic and well maintained. EVIDENCE: St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 16 In compliance with a requirement under Standard 24 at the last inspection, self-closing door mechanisms had been fitted on all bedroom doors. The service users occupy single bedrooms that contain en-suite bathroom and toilet facilities. All bedrooms viewed were attractively decorated and furnished and reflected personal choices and interests. The toilet and bathroom facilities are appropriate for meeting the needs of the service users. The communal areas are spacious and suitable for shared or individual activity. Specialist equipment is in place for assisting the service users and includes parker baths, adjustable beds and chairs, bath seats, hoists and parker baths. Overall, the home was found to be clean, hygienic and well maintained. The atmosphere was calm and pleasant. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 and 35. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. Requirements under Standards 33, 34 and 35 at the last inspection have been met. These related to staffing and documents within recruitment files and training. Care support workers are being appropriately supported and supervised. EVIDENCE: A number of recruitment files were viewed at random and were found to contain appropriate job descriptions. In compliance with requirements under Standard 33 and 34 at the last inspection, the Registered Manager confirmed that two new care support workers had been employed by the home following the last inspection. Recruitment files that were inspected at random contained recent photographs and a CRB disclosure certificate relating to specific service user was on file. Individual training programmes were in place and it was reflected that staff training delivered since the last inspection included, medication, moving and handling, incontinence, values and attitudes and protection of vulnerable St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 18 adults. This complied with requirements under Standard 35 at the last inspection. The records were indicative of regular supervision, staff meetings and annual appraisals being delivered to the care support workers. Care support workers who spoke to the Inspector expressed satisfaction with the levels of training and support they received at the home. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 19 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): 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement had been made using available evidence including a visit to this service. The ethos of the home is beneficial to the needs of the service users. Requirements under Standards 39, 41 and 42 at the last inspection have been met. These related to quality assurance, records, fire safety and health and safety checks. The business and financial plan and Employers Liability Insurance Certificate are satisfactory. EVIDENCE: The Inspector was informed by the Registered Manager that the ethos of the home was based on creating a homely environment for the service users in which they were treated with respect and dignity. There was an emphasis on individuality and placing the person before the disability. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 20 Appropriate quality assurance exercises that had been undertaken were evidenced on documents viewed and met with a requirement under Standard 39 at the last inspection. The home’s policies and procedures were in place and reviewed in June 2006. All records examined were satisfactorily maintained and secured and complied with a requirement under Standard 41 at the last inspection. In compliance with requirements under Standards 42 at the last inspection, the records indicated that up-to-date fire safety checks and fire drills had been undertaken. Tests for legionella had been carried out on 5th July 2006. Gas maintenance occurred on 12th July 2006 and a fire risk assessment was undertaken on 4th August 2006. The home’s business and financial plan dated April 2006 – April 2007 was inspected and found to be satisfactory. A valid Employers Liability Certificate of Insurance was in place. St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X X 3 3 3 3 3 3 St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 22 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 YA1 Regulation 4(2) Requirement The Registered Person must ensure that the service users’ guide is available for inspection. Dates of opening must be recorded on all liquid medication. This is restated from the last inspection. Previous timescale 07/07/06 Timescale for action 30/06/07 2 YA20 13(2) 15/11/06 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 St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Raphaels DS0000022900.V313976.R01.S.doc Version 5.2 Page 24 - 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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