Inspection on 09/07/07 for Stephendale Road, 78-80

This inspection was carried out on 9th July 2007.

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 no outstanding requirements from the previous inspection report, but made 6 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 10/06/06

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:

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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 Stephendale Road 78-80 Stephendale Road Fulham London SW6 2PQ Lead Inspector Jacqueline Derbyshire Unannounced Inspection 9th July 2007 10:00 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 Stephendale Road, 78-80 DS0000019144.V345713.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. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 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) rob.walker@yarrowhousing.org.uk Yarrow Housing Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th June 2006 Brief Description of the Service: Stephendale Road is the home for 6 people 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 4 people living at Stephendale Road presently, each person 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/dinning area. The weekly charge for Stephendale Road is £ 1,503.22. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 9th July 2007; the inspector spent 5.00 hours visiting the home. The Inspector spoke with all of the people living at the home, the new Manager, the Deputy manager and staff. The Inspector checked the care records of two residents; two of the residents finance records and all medication records. All of the residents 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 day of this inspection. 2 requirements that were set June 2006 have been met; 6 new requirements have been made from this visit, with two good practice recommendations. There is a new Manager who has been working at Stephendale road for three months who will register with the CSCI for this establishment. There are issues that not all staff are up to date with mandatory training, the Deputy Manager liaised quickly with the training department and all staff will be put on the next relevant courses. What the service does well: What has improved since the last inspection? The Kitchen has been replaced and the residents told the Inspector they really like it. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stephendale Road, 78-80 DS0000019144.V345713.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 Stephendale Road, 78-80 DS0000019144.V345713.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective individuals are given the opportunity to spend time in the home. EVIDENCE: The Inspector looked at two residents files and records were in place that showed how the home would be suitable for each person. All prospective residents have their needs 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. The Inspector met with all four residents and all stated they were happy living at Stephendale Road. The two residents files that the Inspector checked had records of the people visiting the home before moving there. In discussion with staff this procedure should happen for all new residents. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of care. Staff understand the importance of residents being supported to take control of their own lives. EVIDENCE: The Inspector looked at two residents files that were very comprehensive and had care plans that show how the home is going to meet the individual’s needs. Review records were all up to date with records showing how aims will be met. In discussion with two of the residents they were happy to talk about their (PCP’s) and how they had done a presentation showing pictures and drawings of their likes and dislikes and what their future aspirations are. The Inspector looked at the (PCP’s) and discussed the progression with them in the home. Two of the residents do look after their own finances and will be escorted to their bank, two residents require more assistance. The Inspector checked the financial transactions and monies kept for the four residents and all was seen to be recorded correctly with the relevant balance in place. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 10 The Inspector saw risk assessments in the two files that were comprehensive and up to date. One of the residents is being supported in maintaing their independence and the plans are in place to show how the staff are enabling her to do this. There is a requirement that fire evacuation risk assessments are in place for all four residents living at Stephendale Road. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have the opportunity to develop and maintain important personal family relationships, and are able to access information and specialist guidance about issues such as intimate relationships. EVIDENCE: All of the residents have an activity plan that was written in their files and also on the notice board in the office and the kitchen/dinning room. The residents all attend different venue’s in the local community where they participate in activities. One of the residents attends Options daily, the resident told the Inspector that she enjoyed going out and was able to travel most of the way on her own and that she would call the home on her mobile to inform them she had arrived. Two of the residents had been taken out on the day of the Inspection, one to a lunch club and one to get her hair coloured. The other resident was looking at photographs in her room and told the Inspector that she was cooking dinner that evening. The resident was also excited that her boyfriend was calling to see her the next day to discuss their forthcoming holiday to Edinburough. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 12 In discussion with the Manger the Inspector was told that three of the residents do have family and friends visiting Stephendale Road, two of the residents also go to see their friends on a regular basis. Three of the residents enjoy going to church on a Sunday morning and the Manager makes sure that there are sufficient staff on duty to enable them to do so. There is a TV, video and music centre in the lounge. The Inspector looked at the weekly menu that all of the residents would participate in putting together at their weekly meeting on a Sunday. In discussion with all of the residents they were happy with the meals and three of the residents told the Inspector that they help prepare the meals. The Inspector saw plenty of fresh fruit and lots of food in the fridge and freezer that ensured that choice was available to all of the residents. The inspector checked the storage of food and it was seen to be adequate with safe temperatures in the fridge and freezer. Stephendale Road, 78-80 DS0000019144.V345713.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19,20 and 21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the varied and individual needs and preferences of the people who use the service. EVIDENCE: Two of the four residents are assisted with personal care; this is done either in the resident’s bedroom or in one of the bathrooms. Two residents spoken with stated that the support they received from staff was enough and that they liked to do as much as possible for themselves. The Inspector looked at two residents files and each contained healthcare records. All of the individual’s regular health care checks had taken place, optical, dental and GP. The Inspector also saw records of appointments with psychiatrists, speech therapists and other professionals. In discussion with staff the Doctor will call at the home if requested. 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.V345713.R01.S.doc Version 5.2 Page 14 There have been two bereavements at Stephendale Road in the last few months and in discussion with the Manager the wishes of the residents were carried out as specified in their care plan. In discussion with one of the residents who told the Inspector that her friends had died and she went to their funeral where there were a lot of people she knew. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand, it is also available in different formats. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. In discussion with the Manager and residents there is an open forum where people can state if they are unhappy about anything. There has been no complaints in the last 12 months at the home. All of the resident’s finances were accurate with financial transactions completed correctly. The finance records for all of the residents are checked by the Manager and Deputy Manager regularly to make sure all records are correct. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,26,28 and 30.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home are encouraged to personalise their bedrooms. EVIDENCE: The Inspector had a full tour of the home and all of the resident’s bedrooms were seen. Two of the residents escorted the Inspector to their bedrooms, both people told the Inspector that they liked their bedrooms; each of the bedrooms had photographs, pictures and were very personalised. One of the residents has requested a key for her bedroom, in discussion with the Manager this is being dealt with and a key will be provided. There is a garden at the back of the home that requires some attention. There is a new kitchen in the home and all of the residents stated they were really pleased with it. The home was clean and tidy. Stephendale Road, 78-80 DS0000019144.V345713.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. There are enough qualified, competent and experienced staff to meet the health and welfare of the people using the service. EVIDENCE: The Inspector looked at the staff rota; there are adequate staff on duty at all times that ensures all of the residents needs will be met. As written in this report the Manager ensures that extra staff are on duty to enable residents to go to church on a Sunday. The Inspector checked the training and development records and also had discussions with staff. Training is not up to date for all staff and in discussion with the Deputy Manager arrangements have been made to make sure all staff attend the training as soon as possible. The Managers and staff should monitor training on a regular basis so that mandatory training is up to date for all. The ratio of staff having completed NVQ’s is below the 50 with only one staff member having completed level 3, and one level 2, there is however 1 member staff at present doing level 2 with 3 imminently due to start. In discussion with the Manager this is due to staff changes and people have left that had qualifications. The Human Resources team based at Yarrow head office carries out all recruitment. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 18 CRB records were checked and all staff has up to date checks completed. The Inspector checked supervision records of two staff that were seen to be up to date; both had also had an annual appraisal. In discussion with the Manager and Deputy Manager this is now working well as they have designated numbers of staff that they supervise. Stephendale Road, 78-80 DS0000019144.V345713.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager has the necessary experience to run the home. EVIDENCE: In discussion with the new Manger the Inspector was told that he has not got the Registered Managers Award (RMA) but will be registering to do this shortly. The Manager has worked in social care for many years and has lots of experience. The Inspector looked at two residents files and each had quality assurance questionnaires in place. The residents had both been assisted by other people to complete the questionnaires, one of the residents was assisted by a member of their family and another resident was assisted by a support worker at Options day centre. The residents had no issues and stated they were happy living at Stephendale Road. Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 20 Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. The Inspector had lots of discussions with the residents living at Stephendale Road and all were able to express their feelings about the staff and the home, and all stated they were happy. Stephendale Road, 78-80 DS0000019144.V345713.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 x 2 3 3 x 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 2 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 3 35 x 36 3 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 3 13 3 14 3 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 4 3 x 3 x x 2 x Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 22 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 Standard YA37 YA39 Regulation 8 26 Requirement The Manager registers with the CSCI. The home to have regular PIC visits by the organisation, as there has not been a visit to the home since February 2007. The Manager to make sure that there is at all times member of staff with first aid training on duty. The Manager to make sure all staff are up to date with food hygiene training. The Manager must have fire risk evacuation assessments for the four people living at the home. The Manager to make sure all staff are up to date with moving and handling. Timescale for action 09/10/07 09/08/07 3 YA42 13 09/12/07 4 5 6 YA42 YA42 YA42 13 13 13 09/10/07 09/08/07 09/08/07 Stephendale Road, 78-80 DS0000019144.V345713.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA37 Good Practice Recommendations The Manager to make sure that the garden is tidied up. The Manager to audit files and old information should be archived. 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