Inspection on 05/04/05 for St Raphaels

This inspection was carried out on 5th April 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Raphaels 17/10/08

St Raphaels 24/10/06

St Raphaels 02/06/06

St Raphaels 24/10/05

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 Gavin Thomas Announced 5 & 6 April 2005 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. St Raphaels Version 1.10 Page 3 SERVICE INFORMATION Name of service St Raphaels Address The Butts, Brentford, Middlesex, TW8 8BQ 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) 0208 560 3745 0208 568 6239 clare.casey@psmgs.org The Francis Taylor Foundation Sister Clare Casey Care Home 19 Category(ies) of Learning disability (19) registration, with number of places St Raphaels Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: One service user aged over 65 not by reason of old age. Date of last inspection 15th December 2004 Brief Description of the Service: St Raphael’s 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 sitauted 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 Version 1.10 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 home made very good progress to implement the requirements made at the last inspection. Improvements have been made with quality assurance and monitoring systems. The quality of records and recording systems have improved. In particular, complaints monitoring, investigation and fire drills. Documents relating to service users are now being introduced in suitable formats. All policies and procedures were also being revised and updated. The service is monitored monthly via visits as required under Regulation 26 of the Care Homes Regulations 2001. The Quality Development Manager is also supporting the Registered Manager in reviewing quality assurance and monitoring systems. St Raphaels Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Raphaels Version 1.10 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 St Raphaels Version 1.10 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) 1 and 2 Good progress had been made in improving the quality of the Statement of Purpose and Service User Guide. A proper assessment process was in place. EVIDENCE: The Statement of Purpose was revised and updated in January 2005. This document now includes all of the criteria as set out in Schedule 1 of the Care Homes Regulations 2001. The Service User Guide has now been produced in a format, which includes pictures and simple written language. This document is now more appropriate to the needs of the service users. Service users have been consulted on the revised document and gave positive feedback. An admissions and assessment procedure was in place. Records examined confirmed this. There was one service user vacancy at the time of this inspection. The assessment process was satisfactory. Service users representatives are informed in writing of the outcome of the assessment and if the home is suitable in meeting the needs of the service user. St Raphaels Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 7 The quality of individual plans of care needs to improve to take into account service users holistic needs. The frequency of reviewing individual plans of care needs to be increased to at least every six months. Good practice systems were in place to support and encourage service users to express their views and opinions about their lives. EVIDENCE: Individual plans of care were in place for all service users. The four individual plans of care examined did not take into account service users holistic needs. The current method of planning a service users care needs focuses on three to four goals at any one time. These are reviewed on an annual basis. This method of care planning is restricted and does not demonstrate how different aspects of care and changes in service users needs are met. The goals as recorded, lacked sufficient detail to ensure consistency and continuity of care. Care plans were being reviewed annually. A system must be introduced for care plans to be reviewed at least every six months. The home has now introduced the Person Centred Planning methodology for devising individual plans of care. The Person Centred Planning Coordinator for the London Borough of Hounslow is supporting the home in implementing this system. This approach will be more detailed with service user involvement. St Raphaels Version 1.10 Page 10 Service users are encouraged to make decisions about their lives. This is enhanced with the implementation of the Person Centred Planning approach to care planning. Discussion with service users suggested that there are no restrictions on service users expressing their views and opinions. The daily log included comments, which confirmed service users involvement in the day-today running of the home. St Raphaels Version 1.10 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 & 17 Social and educational opportunities are well managed, creative and provide daily variation. Meals are provided in accordance with service users choices and preferences, though the recording of meals in one unit must reflect what was actually served. EVIDENCE: Service users attend a “Speaking out group” which is funded and facilitated by the London Borough of Hounslow. This group provides advocacy and enables service users to engage with other service users within the Borough. Service users take part in a full programme of activities. Activities provided by the home include social functions, tabletop activities including basic literacy skills and puzzles and videos. Service users make full use of local amenities and are accompanied by staff to restaurants, sporting/leisure activities and church functions. St Raphaels Version 1.10 Page 12 Thirteen service users were attending college or day centres. A number of service users were spoken to and commented on their lifestyles. The service users said that they were very happy with their daily programmes and looked forward to college and attending the day centres. One service user expressed a keen interest in musicals. The service user’s preference is to watch these on video. Another service user said they go to college to learn about different subjects. Two service users who are no longer able to participate in a full weekly programme are supported by staff to maintain their interests and hobbies in the home. One service user spoken to said the food is good. Service users accompany staff to purchase food locally. Fresh meals are prepared in each unit on a daily basis. Meals are selected with service users on a daily basis. Individual choices are recorded on the record of food served in each unit. Meal times are flexible to accommodate service users commitments. It was noted in one unit that food recorded was repeated within a week and did not demonstrate that a wide range of choice was provided. The Inspector was informed that service users are given a wider choice of meals and this record did not reflect the actual food served. The Dietician advises the home on providing appropriate foods to maintain healthy lifestyles. St Raphaels Version 1.10 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Satisfactory arrangements were in place for ensuring that service users health needs are identified and met. Whilst care staff are familiar with service users personal support needs, in some cases, the method of recording these needs must be more detailed to ensure consistency and continuity of care. EVIDENCE: Varying levels of support are provided for service users personal support needs. Same gender staff are provided for supporting service users with intimate care. The Registered Manager reported that a number of service users have made good progress in taking a shower with minimum/intermittent support. Specific goals for personal support were set in service users care plans. As stated in the section headed “Individual Needs and Choices” of this report, these goals must be more detailed to ensure consistency and continuity of care and for monitoring purposes. The Community Team for People with Learning Disabilities supports the home and service users in accordance with their assessed needs. This includes input from the Speech and Language therapist, Physiotherapist and Psychologist. Referrals are made via the GP for appointments with specialist health care professionals. St Raphaels Version 1.10 Page 14 Service users health needs are monitored and all medical appointments are recorded on individual files. Service users also have an annual health check. One service user explained that they were very well cared for at the home during a period of illness. Two service users were awaiting appointments to see a Neurologist. Both service users are displaying symptoms of slight confusion. The Registered Manager was mindful that a variation of registration might be necessary to assess the suitability of the home for both service users in the future. The home has a policy on the control of medication. Medications were stored in locked cabinets in each unit. One service user was receiving controlled medication. This medication was stored and administered appropriately. One service user was self-medicating. A risk assessment was in place for this arrangement. The service user showed the Inspector the facility they use for the storage of medication in their room. This was satisfactory. The service user also confirmed who they would speak to, if they had any issues in managing their medication. Staff responsible for the administration of medication had received updated training within the last eight months. The Pharmacist carries out audits at the home on a quarterly basis. The Medication Administration Records examined were satisfactory. St Raphaels Version 1.10 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 Good progress has been made with the methods for recording and investigating complaints. Steps have been taken to introduce a complaints procedure, which is suitable to the needs of service users. Procedures were in place to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a detailed complaints procedure in place. The complaints procedure has been simplified with basic text and pictures in a separate document for the benefit of service users. The complaints procedure is also available in the form of a leaflet. Two relatives indicated in the surveys that they were not aware of the home’s complaints procedure. The record of complaints showed that the last complaint received in the home was in September 2004. The procedure for recording and investigating complaints was revised and updated in February 2005. This revised procedure is robust and includes various stages and requirements for investigating and reaching an outcome for any complaint received. A separate record of incidents is maintained. These incidents do not fall within the category of a complaint. The policy on adult protection was being revised at the time of this inspection. A whistle blowing policy was in place. The home was not in receipt of a copy of the Department of Health “No Secrets” guidance document and was advised to obtain a copy. Updated training on adult protection has been schedule for 14th April 2005. St Raphaels Version 1.10 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 & 30 The environment was welcoming and homely. The home is maintained at a very high standard. Service users are provided with safe and comfortable surroundings. EVIDENCE: The home was very clean and well kept throughout. None of the areas inspected were in disrepair. Good quality furniture was provided in all three units and bedrooms. One service user confirmed that they chose the colour of their bedroom and the carpet. The home had acted on all requirements made at the last inspection relating to the environment. The roof of the sheltered area in the courtyard has been removed for safety purposes. The home intends to replace this in the near future. The communal grounds and gardens, which are shared jointly with another residential home, were well kept. Service users said they were happy with the environment and referred to it as “their home”. St Raphaels Version 1.10 Page 17 A maintenance log was in place. Routine maintenance and upkeep of the building and fabric were included in the annual budget and a five yearly business plan. A policy on the control of infection was in place. This policy was being reviewed at the time of this inspection. Laundry facilities are provided on the ground floor of Fatima House and St Raphael’s. Both laundry rooms are situated away from food preparation areas. There was no evidence to confirm that the washing facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. This must be obtained. St Raphaels Version 1.10 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) 35 The home does well in providing training opportunities for staff. The frequency of training however, must be evidenced in a more detailed training programme for the current year. EVIDENCE: A three monthly training programme was in place. This programme must be more detailed indicating the types of training, timescales and staff nominated for the training. Evidence of staff training is retained on individual staff files. Individual records of training are maintained. Training assessments must be implemented. Five staff had completed the LDAF training. A further five staff were working towards this programme. This programme included an induction programme. The Inspector was advised that foundation training was included in the NVQ Level 2. Further evidence is required to support this. A training budget was in place. This was also included in the home’s business plan. St Raphaels Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Good progress is being made in developing quality assurance and monitoring systems. Positive steps were also being taken to ensure that records and documents relating to the day to day running of the home are available in all three units. Overall health and safety systems were well maintained. EVIDENCE: The Quality Development Manager had carried out a quality audit. Work was being done to address the shortfalls identified in the quality audit. This audit was comprehensive and included many aspects of the day-to-day running of the home. The Quality Development Manager and the Registered Manager were in the process of devising an annual development plan. A collective survey was carried out with service users in a meeting in January 2004. Subsequent surveys were carried out with service users on an individual basis with assistance from staff. The home was advised that where possible, service users should be assisted with people independent to the home for completing surveys. St Raphaels Version 1.10 Page 20 Monthly unannounced visits are carried out as required under Regulation 26 of the Care Homes Regulations 2001. Copies of reports for these visits are supplied to the CSCI. Further work required to demonstrate that the quality of care reviewed must include publicising the outcome of service users surveys and seeking the views of staff and significant others. Staff had completed and due to attend further training this year in First Aid, moving and handling, food safety, fire safety and health and safety. The health and safety policy in place was revised and updated in February 2005. Health and safety and fire risk assessments were in place and reviewed periodically. Health and safety risk assessments were robust. Records examined indicated that an approved contractor last tested hot water temperatures in April 2004. Although the Registered Manager explained that subsequent tests have been carried out, documentary evidence was not available to support this. Records of interim hot water temperature tests carried out by staff were inadequate. The record must be revised to include the full date, location, appliance tested, temperature reading, any necessary action to be taken and the signature of the staff taking the temperature. A legionella test was carried out in February 2005. The outcome was satisfactory. Fire drill are carried out monthly. The record of fire drills did not include the time of the drill. This record was amended at the time of the inspection to include the times of fire drills. Fire safety checks are carried out and recorded. A fire emergency plan was not in place. Records indicated that safety checks are carried out on gas and portable electrical appliances. A safety check had not been carried out on the electric hob in St Raphael’s. St Raphaels Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 St Raphaels 3 3 3 3 x Standard No 31 32 33 34 35 36 Score x x x x 2 x Version 1.10 Page 22 16 17 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x St Raphaels Version 1.10 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15(1)(2)( b) Requirement Timescale for action 31 July 2005 2. 17 3. 18 4. 5. 23 30 6. 35 7. 35 Service users plans must be in sufficient detail to provide clear guidance to staff on actions to be taken to meet their health and welfare needs. Service user plans must be kept under review at least every six months. 17(2) The record of food served on the Schedule ground floor in Fatima House 4(13) must be more accurate to reflect the actual food served to service users. 12(1)(b) Identified goals for supporting service users with personal care tasks must be more detailed to ensure consistency and continuity of care. 13(6) The home must obtain a copy of the Department of Health No Secrets guidance document. 13(4) (c ) Evidence must be obtained to confirm that the washing facilities and services comply with the Water Supply (Water Fittings) Regulations 1999. 18(1)(a) The staff training programme must be more detailed indicating the types of training, timescales and staff nominated for the training. 18(1)(a)(c Staff training assessments must Version 1.10 31 May 2005 31 July 2005 31 May 2005 30 June 2005 31 May 2005 31 May Page 24 St Raphaels )(i) 8. 9. 35 39 18(1)(a) 24(1)(a)( b)(2)(3) be devised and implemented. Evidence must be obtained to confirm that foundation training is included in the NVQ Level 2. The outcome of service users surveys must be published. The home must also seek the views of staff and significant others as part of the quality assurance and monitoring system. The record of hot water temperature tests must be revised to include the full date, location, appliance tested, temperature reading, any necessary action to be taken and the signature of the staff taking the temperature. A fire emergency plan must be devised and implemented. Routine safety checks must be carried on the electric hob in St Raphaels. 2005 6 May 2005 31 July 2005 10. 42 13(4)( c) 6 May 2005 11. 12. 42 42 23(4)( c) (iii) 23(2)( c) 31 May 2005 31 May 2005 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 39 Good Practice Recommendations Where possible, service users should be assisted with people independent to the home for completing surveys. St Raphaels Version 1.10 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. Extracts may not be used or reproduced without the express permission of CSCI St Raphaels Version 1.10 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!