Inspection on 18/11/05 for Walterton Road (Flat A&B)

This inspection was carried out on 18th November 2005.

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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walterton Road (Flat A&B) 06/06/08

Walterton Road (Flat A&B) 27/04/07

Walterton Road (Flat A&B) 11/05/06

Walterton Road (Flat A&B) 20/04/05

Walterton Road (Flat A&B) 03/11/04

Walterton Road (Flat A&B) 13/05/04

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Edenvale

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Chatsworth Care - Dawson House

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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 Flat A & B 65 Walterton Road London W9 3PF Lead Inspector Wynne Price-Rees Unannounced Inspection 18th November 2005 10:30 Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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 Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Flat A & B Address 65 Walterton Road London W9 3PF 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) 020 7289 0533 The Westminster Society for People with Learning Disabilities Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 Brief Description of the Service: The home is located in the Maida Vale area with easy access to transport and local amenities including shops. It is registered to provide support for up to ten younger adults with learning disabilities and the accommodation has a lift and is located on the ground and first floors. There is a current full occupancy. The building is in a Victorian terraced suburban street and blends in with its surroundings. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Until recently the two floors were registered separately and now the registration and staff teams have been amalgamated with one Care Manager. During the inspection a sample of six files were case tracked and a tour of the building took place. A number of residents were attending a day centre during the inspection and three residents were spoken with. The inspection took seven hours over two days. At the previous inspections of both home’s immediate requirements were left. At subsequent follow up visits the requirements were met although one more requirement was made regarding the need to update goals to reflect progress made within care plans. This is currently being undertaken although it has not been completed. At this inspection one new resident has not got a care plan in place due to the assessment information forwarded by the previous home in which they resided. The placement has gone ahead as the home’s staff team and that of the previous home have been swapping a lot of verbal information and the prospective resident visited the home on a number of occasions to ascertain if the placement was appropriate. What the service does well: What has improved since the last inspection? What they could do better: Focus the daily entry logs on progress made towards goals identified within the care plans rather than being prescriptive of a resident’s day. The medication administration records on the ground floor contained recording gaps without written explanation. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 6 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. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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 Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards two, three and four were inspected and three and four were found to be met, whilst two was not met. Prospective residents are able to visit prior to making a decision about moving in, their needs were partially assessed and they know they will be met. EVIDENCE: One new resident has moved in since the registrations have been amalgamated and underwent a series of visits, accompanied by members of staff from the home they were transferring from. Staff from that home have inducted three staff at Walterton Road who will have primary responsibility for providing care for the new resident and these in turn are inducting the rest of the staff team by ensuring that one of these staff are on duty on each shift. There is a video format included. Although written assessment information was forwarded, some of it was old, had not recently been reviewed and was not comprehensive. An example of this was the arrangements for the resident’s finances. It was unclear who had control of this although staff said it was relatives who frequently visit. This has resulted in a problem with money being available, on site if the resident wished to go out for a meal or purchases are required to be made. Information regarding the resident’s meal preferences was also scant. The needs of the new resident were being met on a basic level although the staff are working on this as they compile more information regarding likes, dislikes and interests in conjunction with the day centre attended. The written assessment procedure has not changed. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards six and nine were inspected and found to not to be met. Not all residents had assessed and changing needs incorporated in goals contained within personal care plans that were underpinned by risk assessments. EVIDENCE: The new resident did not have a care plan although a risk assessment had been forwarded that was dated 27/02/05 with a review date of 27/07/05. It was unclear if this had taken place. Currently the care planning system is being reviewed and updated by the Care manager and staff team. This means that the quality and clarity varied, particularly between the two floors. On the ground floor the system contained a lot of information that was located in a variety of different files, repeated and made it difficult to find and corroborate whilst on the first floor the information had been condensed into one file with separate health information that made it far more user friendly. The system is to be introduced on the ground floor once it has been completed on the first floor. Individual risk taking policies were on file and regularly reviewed in some instances. Two residents did not have risk assessments in place. A new form is being introduced that underpins and enables the care plan goals set. The care plans were tracked on six files and the main problematic area was the recording of daily progress notes that were prescriptive of a resident’s day and made it difficult to track progress made towards goals set despite specific care Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 10 areas being identified. Some reviews had not taken place within agreed timescales although three were due to take place the week after the inspection. Staff said this had happened for a number of reasons but primarily because some of the designated social workers could not make the agreed meetings. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards thirteen and fourteen were inspected and found to be met. Residents have the opportunity to take part in appropriate activities of their choice including those within the local community. EVIDENCE: The residents are provided with a comprehensive choice of group and individual activities provided by the day centres they attend during the week and the home on weekends and in the evenings. These are tailored to their hobbies, interests and cultural needs and are home and community based. They included shopping, restaurant visits, parks and pub quizzes organised by Croxley Road. Extra home staff are rotered, on weekends, to enable residents to pursue interests of their choice. Holidays have also taken place and one resident went to Trinidad in April as part of an identified goal within their care plan to meet relatives. Other holiday destinations were Centre Parcs, Spain and one resident went to Wiltshire for a weekend. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards eighteen and twenty were inspected and standard eighteen was met whilst standard twenty was not met. Residents receive personal support in their preferred way and medication is appropriately administered including recording. EVIDENCE: Observation of care practices and the health care files demonstrated that personal care is provided in a manner preferred by the individual residents. The residents are all registered with GPs and have access to community based health care services including dentists and chiropodists who either visit the home or residents visit them. A lot of extra training has been provided to equip the staff team to meet the varied and complicated health needs of the new resident. A manual-handling course took place the day prior to the inspection particularly focused on the new resident’s needs, as they are more physically dependent. Rectal diazepam training also took place on the second inspection day. The medication administration records for each resident were inspected and gaps were found in some recordings without adequate written explanation provided. There is a written medication policy and procedure in place. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards twenty-two and twenty-three were inspected and found to be met. Residents’ views are listened to, acted upon and they are protected from abuse, neglect and self-harm. EVIDENCE: All staff have received adult protection training and are fully aware of the procedure to be followed in the event of abuse being encountered. The organisation is also aware of the POVA and POCA referral procedure. The complaints book was checked and found to be fully documented with outcomes. This was checked and counter signed by the home’s service management. There is a policy and procedure that is included in semi-pictorial form in the residents guide and that staff have access to. Complaints are responded to within twenty-eight days and training has been given to support residents to make a complaint. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards twenty-four, twenty-seven and thirty were inspected and twentyfour and thirty were found to be met. The home provides a warm, comfortable, clean, hygienic and safe environment with sufficient toilets and bathrooms to meet residents’ needs although the shower chair for the new resident must be assessed by a physiotherapist to identify if it is safe to use and therefore twenty-seven was not met. EVIDENCE: A tour of the building showed that residents are provided with a safe, homely, warm and comfortable environment to live in. Concerns were expressed by the family of the new resident and staff about the appropriateness and safety of the shower chair used for transfer that accompanied them from the previous home. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 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): Standards thirty-two and thirty-four were inspected and found to be met. The home has competent and qualified staff that have completed a thorough recruitment procedure prior to appointment. EVIDENCE: Since the registration amalgamation much work is being done to integrate staff into one team with staff rotered to carry out shifts on both floors to familiarise themselves with the residents and each other. Observation of care provided and the way that residents were supported, consulted and spoken with demonstrated that there is an efficient, caring and professional staff team in place. There are two full time care worker vacancies with interviews scheduled for 01/12/05. In the interim the related shifts are being covered in-house and by short-term agency contracts to provide continuity of care. The project has a comprehensive recruitment procedure that is based on equal opportunities. Copies of staff contracts that include employment terms and condition are held by the organisation’s HR department. Staff performance is reviewed three and six monthly in their first year of employment and annually there after. There are also annual appraisals. All staff have been CRB cleared or are awaiting a CRB response and those without clearance do not work unsupervised unless they have received the POVA check. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 16 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): Standards thirty-seven and thirty-nine were inspected and standard thirtyseven was met whilst thirty-nine was not met. The home is well run and residents’ views underpin the quality assurance system although the monthly proprietor visit reports have been received intermittently at the CSCI office. EVIDENCE: The Care Manager is an RGN, holds a certificate in management studies, diploma in learning disabilities and has extensive experience at care manager and service manager level. They displayed very good service management knowledge and leadership qualities during the inspection. The monthly unannounced proprietor visit reports were received intermittently at the CSCI office and did not always identify the shortfalls in standards found during the inspection as part of the quality assurance system. Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 17 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 2 3 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Flat A & B Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000042266.V257912.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 12 Requirement Assessed information received must be up to date and complete to make sure the placement is appropriate to meet needs. A float must be made available so that the resident has access to funds when they require them. All residents must have up to date risk assessments in place. The daily log sheets must reflect progress made towards care plan goals set rather than prescriptive of a resident’s day. A care plan must be provided for the new resident. Care plan reviews must take place within agreed timescales. The medication administration records must be fully completed following the symbol chart. A physiotherapist’s report must be commissioned regarding the safety of the new resident’s shower chair for transfer. The proprietor’s monthlyunannounced visits must take place with accompanying report sent to the CSCI on completion. The monthly visits must DS0000042266.V257912.R01.S.doc Timescale for action 19/11/05 2. YA2 12 19/11/05 3. 4. YA9 YA6 13 15 01/02/06 01/02/06 5. 6. 7. 8. YA6 YA6 YA20 YA27 15 15 13 13 19/12/05 01/02/06 19/11/05 01/01/06 9. YA39 26 19/11/05 10. Flat A & B YA39 24 19/11/05 Page 19 Version 5.0 endeavour to identify shortfalls in the standards as part of the quality assurance system. 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 Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 20 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 Flat A & B DS0000042266.V257912.R01.S.doc Version 5.0 Page 21 - 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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