Inspection on 19/06/06 for Talgarth Road

This inspection was carried out on 19th June 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Talgarth Road 01/12/09

Talgarth Road 05/11/07

Talgarth Road 28/02/06

Talgarth Road 22/08/05

Talgarth Road 21/02/05

Talgarth Road 15/06/04

Talgarth Road 22/03/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Talgarth Road Talgarth Road 41-43 Talgarth Road West Kensington London W14 9DD Lead Inspector Tony Lawrence Unannounced Inspection 19th June 2006 09:00 Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Talgarth Road DS0000019148.V292466.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. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Talgarth Road Address Talgarth Road 41-43 Talgarth Road West Kensington London W14 9DD 020 7603 8607 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) Hestia Housing Ms Lyris Ofosu Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Talgarth Road is a registered care home providing personal care and accommodation for up to ten people with mental health support needs. At the time of this inspection, 5 men and 5 women were living in the home and there were no vacancies. The home is managed by Hestia Housing and Support and the building is owned by the Shepherds Bush Housing Association. The home is situated in the West Kensington area with access to local amenities and good transport links. Each service user has his/her own bedroom and shared use of lounges, kitchen, bathrooms and toilets. There is a large garden. Talgarth Road DS0000019148.V292466.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 19th June 2006 from 09:00 – 13:30. The Inspector spoke with service users, staff and the home’s Manager, checked care records and toured the building. The home is well staffed and standards of care, accommodation and record keeping are good. All eleven requirements made after the last inspection in February 2006 have been met. The weekly fee for the service is £850. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 6 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 Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 7 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): 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has clear referral and admission policies and procedures that enable service users to make a positive choice to move into the home. EVIDENCE: There has been no change to the group of service users living at Talgarth Road since the last inspection in February 2006. The Manager confirmed that any vacancies are reported to the Social Services Department and referrals are then accepted from local Mental Health Teams. The home’s Manager said she requires detailed information about potential new service users before they visit and a Care Programme Approach (CPA) care plan review is always held six weeks after someone moves in. Two service users who spoke with the Inspector during this visit said that they had visited the home before moving in. Both people said they found these visits helpful as they were able to meet other people living in the home and staff, as well as viewing the accommodation. Both people said that they had stayed overnight before moving in. The two care plan files reviewed by the Inspector during this visit each included a Licence Agreement that details the service user’s rights and responsibilities. Both Licences were signed by the service user and staff. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 8 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 excellent. This judgement has been made using available evidence, including a visit to this service. The care needs of people living in the home are well assessed and recorded and are regularly reviewed. Service users are fully involved in the home’s care planning procedures. EVIDENCE: During this visit the Inspector tracked the care of two people living in the home. The Inspector spoke with both people and staff working with them and checked care records kept in the home. The two care plan files were up to date and included all of the information needed to meet these Standards. Both people have a Care Programme Approach (CPA) care plan and the home’s own care plan. One CPA plan was reviewed in May 2006 and the second person’s plan was due to be reviewed the week after this inspection. The home’s own care plans for both people were reviewed in May 2006. Both plans included some clear goals designed to improve individual’s independence in a number of areas, including daily living skills, mental and physical health, personal care and activities. An example of good practice was the regular updating of plans to include outcomes for service users. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 9 Daily care notes are well completed by staff and records of monthly meetings with each person’s key worker are up to date. These provide a useful overview of the care received each month, as well as progress in meeting agreed goals. Care plans and key worker reports were all signed by the service user and a member of staff. Both care plan files reviewed by the Inspector during this visit included current risk assessments that had been regularly reviewed. These clearly identified potential risks to individuals and actions that need to be taken to minimise these. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 10 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff support service users to identify and take part in a range of social and leisure activities. Service users are fully involved in planning and preparing meals. EVIDENCE: The Inspector saw a weekly programme of in-house activities that is available to service users. Sessions include music, computing, current affairs, social skills, assertiveness and separate groups for men and women living in the home. Service users who spoke with the Inspector said that they enjoyed the groups and the way these are run by staff. In addition to the in-house programme, service users said that they use local day and employment services. During this inspection, some service users were attending day services, some were at home and staff supported other people to go to appointments and the bank. The home is well equipped to enable service users to take part in leisure activities. There is a large TV lounge and a separate quiet lounge with a Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 11 personal computer and music system. Service users also said that they can relax in their rooms. Service users’ care plans include details of relatives, friends and other significant people. Service users told the Inspector that relationships in the home are generally good, although disagreements do happen. Service users said that these are usually resolved by staff on duty. One person also said that they could raise issues in the weekly house meeting where they were confident they would be treated seriously. Two people living in the home mentioned the complaints procedure and said that they would use this for more serious issues. Both care plans reviewed during this visit included a Licence Agreement that clearly outlines the rights and responsibilities of people living in the home. Two service users told the Inspector that their key worker had explained the Licence to them shortly after they moved into the home. Five people living in the home said that they enjoy the food that is provided. During this visit, service users prepared and ate a meal of Irish stew, potatoes and mixed vegetables with ice-cream for dessert. Two people living in the home told the Inspector that they had enjoyed the meal. Menus are planned at the weekly house meeting and service users are encouraged to participate in shopping and cooking lunch and the evening meal. Service users said that the food is varied and nutritious. The kitchen / dining room is well equipped and provides a satisfactory space for service users to eat their meals. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 12 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. Service users’ health and personal care needs are well assessed and recorded. Medication is managed safely. EVIDENCE: The two care plans reviewed during this visit included assessments of each person’s health and personal care needs. Both plans included clear goals relating to mental and physical health issues, medication and personal care. There was evidence in the care plans that service users are involved in agreeing goals and people living in the home confirmed this. The daily care notes and monthly key work reports written by staff are related to the goals identified in each individual’s care plan. Both plans also included detailed information about the person’s health care needs and how these are met by the multi-disciplinary team responsible for their care. Both plans included evidence of appropriate referrals to health and social care professionals. The home uses the Boots Monitored Dosage System for all prescribed medication. The Inspector checked the storage arrangements and medication records for each service user. Standards of medication management and recording in the home are good. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence, including a visit to this service. Service users are consulted about the care they receive. Policies and procedures are in place to make sure that people are cared for safely. EVIDENCE: The home’s complaints record shows that there have been three formal complaints since December 2005. The home’s manager and staff dealt with two complaints and the records show that the people who complained were satisfied with the outcomes. The third complaint was formally investigated by the Deputy Manager. A report was written after the investigation and this also included evidence that the complainant was satisfied with the outcome. The last inspection report included requirements that staff must follow the local authority’s adult protection policy and procedures. The Manager confirmed that there have been no concerns or allegations since the last inspection. Staff who spoke with the Inspector were able to describe how they would respond to concerns and allegations. Since the last inspection, the Inspector has been satisfied that staff have been appropriately reporting significant incidents to the Commission. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from good standards of private and communal accommodation. EVIDENCE: 41-43 Talgarth Road comprises two large, inter-connected houses close to the shops and transport links of West Kensington and Hammersmith Broadway. Each service user has a single room. Lounges, bathrooms, toilets, the kitchen / dining room, laundry room and garden are shared. The Inspector saw all communal parts of the home and three bedrooms during this visit. Lounges are comfortably furnished and standards of decoration have improved since the last inspection. Service users’ bedrooms are well decorated and furnished and staff have supported people to personalise their own rooms. There is a sufficient number of bathrooms, showers and toilets, situated close to service users’ bedrooms and communal areas. These areas are adequate, but there is a need to clean or replace bath and pedestal mats. The home’s part-time cleaner was working during this visit and all parts of the home seen by the inspector were clean and tidy. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 15 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, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users are supported by competent staff. Arrangements are in place to make sure that the home meets the required target for qualified staff during 2006. EVIDENCE: The Inspector checked the home’s staff rota and this accurately showed the number of staff on duty. When the Inspector arrived, the Manager, three Project Workers and the home’s part-time cleaner were on duty. The Deputy Manager and another Project Worker started shifts later in the day. The Inspector feels that staffing levels in the home are sufficient to meet the care needs of service users. The Manager confirmed that two Project Workers and the Deputy Manager have completed their National Vocational Qualification (NVQ) Level 3 training. The Deputy Manager and one other member of staff are currently completing their Level 4 qualification. One other member of staff is completing the NVQ Level 3 training and another has submitted their portfolio to complete their Level 2 training. Although the home did not meet the target of 31/12/05 for providing 50 NVQ qualified staff, the Inspector is confident that arrangements are in place to make sure the target is achieved during 2006. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 16 The Manager provided the Inspector with a list of Criminal Record Bureau Enhanced Disclosures for all permanent, agency and bank staff working in the home. Staff told the Inspector that the organisation provides good training opportunities. As well as their NVQ qualifications, various staff have completed other training, including adult protection, first aid, managing aggression, food hygiene, supervision and manual handling. Two staff have also completed foundation training on the care of medicines organised by Boots. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 17 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): 37, 39, 40, 41 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is well managed and standards of record keeping are good. Some health and safety issues need to be addressed. EVIDENCE: The home has a permanent, experienced and qualified manager who has been registered by the Commission. Staff on duty during this inspection were clear about the management arrangements in the home, including arrangements for out of hours support and advice. Four people living in the home told the Inspector that they are consulted about the care and support they receive and all said that they feel their views are listened to by staff and managers in the home and the wider organisation. Service users and staff mentioned the weekly house meetings that are held. Staff said that 7 or 8 service users usually attend and recent discussions have included repairs, the home’s smoking policy and complaints. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 Page 18 The Manager reported that there is a meeting that involves service users and staff every 6 months to discuss quality assurance systems in the home. The agenda for the next meeting includes changes to CSCI inspections, service user involvement in running the home, Hestia’s Tenants’ Forum, health and safety and refurbishment plans. Monthly unannounced visits are made to the home by managers from the service provider. Written reports are sent to the home and the Commission after each visit. The reports include information about contact with service users during the visits and their views and comments are recorded. The home has all of the policies and procedures required to meet these Standards and there is evidence that these are reviewed by the service provider. Standards of record keeping in the home are good. The recording of health and safety checks is also good, although some checks are overdue. Food storage temperatures are recorded daily. Weekly fire alarm and emergency lighting tests are well recorded. Monthly fire drills and false alarms are also recorded, but there is a need to make sure that a record is kept of action taken if service users do not respond when the fire alarm sounds. A full health and safety audit was completed in May 2006. It is an example of good practice that a service user is the nominated health and safety representative for the people living in the home. This person told the Inspector that he was fully involved in completing the recent audit. A workplace risk assessment was completed in July 2005 and the manager confirmed that all issues arising have been dealt with. A local authority Environmental Health Officer completed a food safety inspection in May 2005. There is a need to make sure that current gas and electric safety certificates are obtained as those available in the home are dated April and August 2003. Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 2 X Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 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. Standard YA27 YA42 Regulation 23 23 Requirement Bath and pedestal mats in bathrooms and toilets must be cleaned or replaced. A record must be kept of action taken if service users do not respond when the fire alarm sounds. Current gas and electric safety certificates must be obtained. Timescale for action 31/08/06 31/08/06 3. YA42 23 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 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 Talgarth Road DS0000019148.V292466.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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