Inspection on 10/06/06 for Stephendale Road, 78-80

This inspection was carried out on 10th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stephendale Road, 78-80 17/06/09

Stephendale Road, 78-80 19/08/08

Stephendale Road, 78-80 09/07/07

Stephendale Road, 78-80 06/09/05

Stephendale Road, 78-80 18/01/05

Stephendale Road, 78-80 27/09/04

Stephendale Road, 78-80 09/03/04

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 Stephendale Road, 78-80 Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ Lead Inspector Jacqueline Derbyshire Unannounced Inspection 10/12th June 2006 09:00 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Stephendale Road, 78-80 Address Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ 020 7371 8908 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) info@yarrowhousing.org.uk Yarrow Housing Mr Andrew Gatah Anaro-Wood Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Stephendale Road is the home for 6 service users with a learning disability. The care is provided by Yarrow Housing Limited, which is a voluntary organisation. Notting Hill Housing Trust owns the property. The home is located in a quiet residential street in Fulham and is close to transport links and local amenities. There are 5 service users at present living at the home. Each service user has a single bedroom. There are two bedrooms on the ground floor, two bedrooms on the first floor and another two bedrooms on another level up three steps. Washbasins are in each bedroom. There are WC, bathrooms and shower rooms situated close to bedrooms and communal areas. There is a passenger lift to the first floor. There is a garden to the rear of the home and a lounge and kitchen/dinner. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Friday 10th June and Tuesday 13th June 2006; the inspector spent 7.00 hours visiting the home. The Inspector spoke with all of the service users, the Care Services Manager and staff. The Inspector checked the care records of two service users; two of the service users finance records and medication records. All of the service users bedrooms were looked at and all communal parts of the home. The home provides an adequate standard of accommodation that was seen to be clean and tidy on the two days of the inspections. All of the 9 requirements that were set 20/02/06 have been met; 9 new requirements have been made from this visit. There is a new temporary Manager working at Stephendale road who was not available on both visits and not all records for Health and Safety, Staff and quality assurance were available, these areas will be covered at the next Inspection. What the service does well: What has improved since the last inspection? Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 6 PCP records are in place with all service users reviews up to date. PIC visits are taking place with copies being sent to the CSCI. A new desk has been put in the staff office. All staff records show that all staff have completed dementia awareness training. There are adequate staff on duty, this is an area that needs to be closely monitored in conjunction with activity plans. The Deputy Manager is not registering with the CSCI a temporary Manager is in place. If the temporary Manager stays for up to three months he will have to register for Stephendale Road. The magnetic door closer has been repaired in the office. 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. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The agency provides a clear and comprehensive Statement of Purpose and Service user guide with prospective service users receiving a copy of both documents. EVIDENCE: The inspector checked the Statement of Purpose and Service user guide, both documents were clear with up to date information in place. These documents are available in different formats including pictures if required. All prospective service user needs are assessed with their aims and aspirations looked at to make sure the home is suitable and that staff are adequately trained to be able to meet them. Contracts were in place for all five-service users, all contracts need to be signed and dated. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person Centred Planning (PCP) records are all up to date with a lot of information in place some of the information is in photographs chosen by the service users. These plans are put in place with the service user whose input is sought throughout the process; this ensures the care plan is what the service user requires from the home. EVIDENCE: Two service user files were looked at that had up to date information in place. In each Person Centred Planning (PCP) document there was a lot of information with specific aims for the person to be met in a six month period or before if possible. Review records were all up to date with records showing how aims will be met. One service user spoken with stated she liked getting her photograph taken for her plan. The PCP plans have greatly improved with all staff having completed the relevant training. Risk assessments were seen to be in place for all of the service users that had been up dated March 2006, relevant actions were in place to minimise any risk. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 10 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): 13,14,15 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities plans need to be suited to each individual and to meet their needs as written in their care plan. EVIDENCE: All of the service users have an activity plan that was written in their files and also on the notice board in the office and the kitchen/dinning room. There is a need for the home to provide a more suitable activity plan for all service users, taking a service user for a walk everyday does not qualify as a way of stimulating that individual, a more varied plan is required. The Manager to liaise with professionals in dementia to seek advice and set up plans from that as three of the service users have some forms of cognitive impairment. There is also a need to make sure that the staffing is sufficient to meet the activity plans. One of the service users told the Inspector that she is going on holiday to Paris in August and she was really looking forward to it. There is a TV, video and music centre in the lounge. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 12 In discussion with staff and service users it was stated that family members of a few of the service users call at the home. Service users spoken with stated they liked the food and enjoyed meal times as all of the service users have their meals together in the kitchen/dinning room. One of the staff and a service user went shopping; fresh fruit was seen on the second visit to the home. Menus were seen in the kitchen with a varied choice of meals offered, resident meeting records were looked at and menus were seen to be on the agenda with service users choosing what they liked for the week ahead. The inspector checked the storage of food and it was seen to be adequate with safe temperatures in the fridge and freezer, the Manager must ensure that temperatures are taken daily. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: All of the five service users are assisted with personal care; this is done either in the service users bedroom or in one of the bathrooms. One service user spoken with stated she felt that the support she received from staff was enough and that she liked to do as much as possible for herself. All service user health needs are being met in discussion with staff and looking at healthcare records all regular check ups are up to date. The records in two files showed how regular appointments have been made with the Psychiatrist with relevant recommendations carried out by staff. The Inspector checked the medication administration records for all of the people living in the home. Overall the Inspector felt that the standard of medication recording was good with all staff following the medication procedure. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 14 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a procedure in place at the home that is used for protection incidents that is known to staff. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. Two service users finances were not accurate and records were incorrect. The finance records for all of the service users should be checked by the Manager regularly to make sure all records are correct. Each record contained a record of all income and expenditure however not all receipts were available for all transactions made on behalf of the service users. There has been one complaint that the CSCI was notified about in the PIQ however the complaint information was not available on the two days of the inspection. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): 24,26,27,28 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are environmental issues that the home needs to meet. EVIDENCE: The Inspector had a tour of the home and all communal areas were seen, there is a need for the kitchen to have new unit doors repaired or replaced and the kitchen /dinning area decorated. Chairs in the TV lounge and dinning chairs need to be replaced due to wear and tear. The upstairs shower to have tiles replaced. All of the service users bedrooms were seen two of the service users showed the Inspector their rooms and stated they liked them and that they were comfortable. There is a need for one of the bedrooms to be deep cleaned, as there is a strong odour. The bedrooms were all personalised with pictures and paintings. The home was clean and tidy on both days of the Inspection. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): 32,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team in the home needs to be of adequate numbers to meet the needs of all of the service users. EVIDENCE: The Inspector looked at the staff rota; there is adequate staff on duty however there is an issue in the home as written in this report that activities need to be introduced that are suitable for individuals and this means sufficient staff have to be on duty to ensure this need is met. On the two days of the inspection staff found it difficult to provide activities to individuals as they were performing other relevant tasks in the home. The Inspector checked the training and development records and also had discussions with staff. Training is up to date with all staff recently completing dementia awareness. The ratio of staff having completed NVQ’s is below the 50 with only one staff member having completed level 3, there are however 3 staff at present doing levels 3 and 4. The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff has up to date checks completed. The Inspector was not able to check supervision records; in discussions with staff it was clear that staff do not have regular meetings. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 18 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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): EVIDENCE: None of the Standards were covered at this Inspection and will be looked at in the next Inspection. Records were not available and the Manager was not present on both days. Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 2 27 2 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 2 15 x 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x x x x x x 2 x Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 21 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 2 3 Standard YA5 YA14 YA23 Regulation 14 16 13 Requirement All service users to sign and date the homes terms and conditions. The home to provide a more varied activities plan to all service users. The Manager to ensure all staff record service users financial transactions correctly. Staff do not put IOU slips in place of the correct financial transaction, records should be completed straight after any transaction has taken place. The chairs in the kitchen and TV lounge to be replaced. One of the service users bedrooms to be deep cleaned, as there is a strong odour. New tiles to be put in place in the upstairs shower. Kitchen units to be repaired or replaced. All staff to have regular supervision sessions with a copy of their supervision given to them that is agreed. All health and safety records are available for inspections by the CSCI. Timescale for action 30/06/06 31/07/06 30/06/06 4 5 6 7 8 YA24 YA26 YA27 YA28 YA36 23 23 23 23 18 13/08/06 30/06/06 13/08/06 13/08/06 13/08/06 9 YA42 23 13/08/06 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 22 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 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hammersmith Local 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 Stephendale Road, 78-80 DS0000019144.V288187.R01.S.doc Version 5.1 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. 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