Inspection on 06/09/05 for Stephendale Road, 78-80

This inspection was carried out on 6th September 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 no outstanding requirements from the previous inspection report, but made 5 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 10/06/06

Stephendale Road, 78-80 18/01/05

Stephendale Road, 78-80 27/09/04

Stephendale Road, 78-80 09/03/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

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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 STEPHENDALE ROAD (78/80) 78/80 Stephendale Road Fulham LONDON SW6 2PQ Lead Inspector Jackie Derbyshire Announced 6 September 2005 @ 09.00 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. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Stephendale Road (78/80) Address 78/80 Stephendale Road, Fulham, London SW6 2PQ 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) 020 7371 8908 Yarrow Housing Ltd Mr Andrew Gatah Anaro-Wood Care Home 6 Category(ies) of Learning Disability (6) registration, with number of places STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12 July 2005 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 6 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) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 06/09/05; the inspector spent 5 hours on site. The inspector spent time checking finance records, medication records, staff rotas, looking at 3 service user files and 3 staff files. Speaking to service users, staff and the Manager. The inspector also had a full tour of the home. 8 out of 10 requirements set in the last inspection have been met; there are 3 new requirements. The inspector received 6 questionnaires from service users and visitors; the comments are incorporated into this report. What the service does well: What has improved since the last inspection? All staff are now correctly following the finance procedure in the home. The Manager who is appointee for 2 service users has up to date records that show all financial transactions that have been carried out for the service users. The home has an adequate number of staff on duty to ensure the needs of all service users are met. All staff have now completed basic first aid training. A Fire evacuation risk assessment has been completed on all service users. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 6 All staff are now aware of how to complete accident and incident forms, and all staff are aware of POVA and how to follow the correct procedure. 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) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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 STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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) 2 and 5 The home has a thorough assessment procedure in place to ensure prospective service users are suitable placed and all their needs can be met by the home. The home provides all service users with a written contract that is agreed signed and dated. EVIDENCE: The inspector checked the file of a service user that has recently moved into Stephendale Road. The file had all relevant information in place including a (CPA) Care Plan Approach that includes all of the service user needs and risk assessments. A care plan is being developed to ensure staff provide the relevant assistance required. 3 service users files were checked and the contracts were seen to be in place. All of the service users were spoken with and 1 of them stated they had agreed the homes terms and conditions and had signed a contract. The service user also stated he was happy with the care provision and liked living at Stephendale Road. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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) 6,7 and 9 The Manager and staff have written care plans that show that service user needs are being met. There is a need for all service users care plans to be reviewed. The homes risk assessments are in place. EVIDENCE: Three service user files were looked at and all had a care plan in place called Person Centred Planning (PCP). 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. The inspector spoke with all of service users who stated they were happy with the assistance they receive and were very happy living at Stephendale Road. The organisation’s risk management systems are well implemented. The assessments included general health and safety issues and risk factors for each service user. The assessments covered daily life in the home and in the local community. Questionnaires that were sent to the inspector by service users and family stated that they were happy at present with the care provision. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 10 STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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) 12,13,14 and 17 The home has activity plans in place that show a varied mix of activities that is suitable for each service users needs. The meals offered by the home offering choice and variety and catering for special dietary needs. EVIDENCE: All of the service users have a full activity plan that was written in their files and on the notice board in the dinning room. In discussion with the Manager and staff it was stated that they try to vary every service users activities plan, at times this can be extremely difficult as the service users will change their mind and will not want to participate, in these instances staff will try to encourage the service users. Service users will go out to local cafes and shops, on the day of the inspection 3 service users were taken out to various venues. Two of the service users have family that visit the home, questionnaires from family members stated they are made welcome by staff at the home. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 12 There is a weekly menu recorded, service users choose their own meals with staff assistance to ensure nutrition is balanced. Three of the service users have to have a soft diet, choice is still given and all food is cut up because of health reasons. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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 and 20 The health and personal care needs of the people living at the home are well known to staff. Service users are supported to be as independent as possible. The systems for the administration of medication are clear, all staff need to ensure that they sign the (MAR) Medication Administration Record for all service users when medication has been given. EVIDENCE: Personal support is provided in the privacy of the service users room or in the bathroom. Three of the service users are semi- independent and complete their own personal care needs with staff assistance. Three service users require full assistance in all care needs. All of the service users have a local GP and are supported to attend appointments. 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. Records looked at for three service users showed that optician, dental and GP visits have been recorded. 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 adequate, as one of the (MAR) Medication Administration Record sheets had not been completed thoroughly. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 14 STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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) 23 The home has made appropriate use of adult protection procedures. EVIDENCE: The home has a protection procedure in place, discussions with staff members showed that they were aware what to do if an incident occurred. Service users finances were well managed and accurate records were kept. The finance records for all of the service users were checked. Each contained a record of all income and expenditure with receipts for all transactions. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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) 24,28 and 30 The home provides a clean comfortable environment for service users. EVIDENCE: A full tour of the home was given and all of the service users bedrooms were seen. The service users stated they liked their rooms. All communal areas were seen to be adequately decorated and furnished. The toilets and bathrooms were looked at and there are sufficient numbers for the service users. There is a need to change the chairs in the office as they are broken and do not meet health and safety standards. The washing machine does not work properly maintenance work need to be carried out quickly as some of the service users are incontinent and have a lot of laundry. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33 and 35 The recruitment procedure in the home is good with good arrangements for the induction of staff. Staff showed a good knowledge of their roles and responsibilities. EVIDENCE: The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff have up to date checks completed. The Manager confirmed that all new staff complete the care services induction programme developed by the Learning Disability Awards Framework (LDAF). All staff have job descriptions and have clearly defined roles and areas of responsibility outlined. The Manager confirmed that Yarrow had a programme of National Vocational Qualification training for all staff in the organisation; six members of staff have completed level 2. The Manager confirmed that there are currently two vacancies for a Residential Support Workers. Yarrow has an annual training programme that is open to all staff. Individual’s training needs are discussed in supervision. The inspector looked at three staff files and up to date supervision and appraisal records were in place for all three. The service users spoken with stated they liked the staff and were happy with the assistance they received. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 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 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) 42 The Manager is well supported by staff to ensure all health; safety and welfare issues are met. EVIDENCE: The inspector felt that the home was very open and friendly, staff and service users were working very closely. Records were checked for the fire alarm and fire drills, all other records ensuring the health, safety and welfare of service users were checked. In discussion with the Manager and staff it was stated that all staff are up to date in health and safety training. All staff have now completed First aid training. STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x 2 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 STEPHENDALE ROAD (78/80) Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 20 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. 4. 5. Standard YA6 YA39 YA20 YA24 YA30 Regulation 15 26 13 23 23 Requirement All service users to have PCP review meetings as specified every 6 months. PIC visit monthly records to be sent to the CSCI.This is a repeat requirement. All staff to ensure that the MAR sheet is signed when medication has been given to service users. The staff office to have new chairs. The washing machine to be repaired. Timescale for action 30/09/05 30/09/05 10/09/05 30/11/05 16/09/05 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 Good Practice Recommendations STEPHENDALE ROAD (78/80) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 21 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) G60-G09 S19144 STEPHENDALE ROAD AIV239111 060905 STAGE 4.doc Version 1.40 Page 22 - 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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