Inspection on 12/05/06 for Worcester Road, 38

This inspection was carried out on 12th May 2006.

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

Other inspections for this house

Worcester Road, 38 20/09/07

Worcester Road, 38 20/10/05

Worcester Road, 38 19/05/05

Worcester Road, 38 09/08/04

Worcester Road, 38 20/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Worcester Road, 38 Cowley Uxbridge Middlesex UB8 3TH Lead Inspector Ms Susan Woolnough-Singh Unannounced Inspection 12th May 2006 10:00 Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Worcester Road, 38 Address Cowley Uxbridge Middlesex UB8 3TH 01895 272794 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) www.mencap.org.uk Royal Mencap Society Holly Southwood Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one service user, currently living there, who is aged above 65 years. 20th October 2005 Date of last inspection Brief Description of the Service: This is a registered home providing personal care to seven service users with a learning disability. New Era Housing Association owns the premises. MENCAP manages the home. The home has seven single bedrooms a lounge and a dining room. There is a bathroom on the ground floor and the first floor. The home has a nine-seated vehicle for the use of service users and is located in a residential area close to shops, public transport and other amenities. The service users are involved in the day-to-day running of the home. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Worcester Road. All of the Key National Minimum Standards for Younger Adults were assessed. The Inspector carried out the inspection over two days. The 12th May 2006 from 10.15am – 17.10 and 19th May from 19.10 to 22.00. On the second day of the inspection time was spent talking with service users in the evening. The Inspector carried out a tour of the home, and inspected service user plans, staff files, and medication records. A new Manager was in post and has yet to apply for registration with the CSCI. The Inspector strongly advised that this is done as possible. The Inspector spoke with three service users, the Manger Designate and two members of staff as part of the inspection process. What the service does well: What has improved since the last inspection? At this inspection and the previous inspection two different Manager Designates were employed at the home. The current Manager is in the process of applying for registration with CSCI. The Manager is experienced and was able to demonstrate knowledge of her role and enthusiasm for change. Two new staff had also been recently recruited to the team. Unfortunately the majority of Requirements had not been met since the last inspection, so there was minimal improvement in this area. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 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. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have an up to date assessment on their personal files. EVIDENCE: The service users at Worcester Road have lived at the home for a number of years. However, London Borough of Hillingdon Community Team for People with Learning Disabilities had recently carried out a further assessment of service users needs. There has been no new service users move into the home since the last inspection. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have individual plans in place, which reflect their care needs, routines and daily choices. Satisfactory risks assessments are in place for service users who are able to act independently. The changing needs of services users must be kept under review to ensure their health and safety. EVIDENCE: The Inspector sampled four care plans, service users have an individual care plan and staff at the home are working with some service users on person centred plans. The Care Plans are comprehensive and cover service user likes and dislikes and daily care needs in detail. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 10 The care plans and person centred plans reflect any choices and decisions service users may have made in regard to their lifestyle. Service users have personalised risk assessments, which indicate any areas of risk, such as travelling alone and carrying out tasks in the home such as making hot drinks. The risks assessments demonstrate that service users are able to act independently of staff. Service users are encouraged to make their own decisions and set their own daily routines, some service users needing more support and motivation than others. House meetings are held the last one being 17th March 2006. Service users discussed the house, outings and staff leaving and new staff starting. The needs of one service user can no longer be met at Worcester Road. The mobility of the service user has declined and she/he is a risk when using the bathroom. (Please see standard 27,29 and 42) A requirement has been made with regard to this under the health and safety standard and regulation. The inspector spoke with the service user who appeared to be aware of his/her circumstances and spoke of the need to live somewhere with additional care and facilities. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers service users independence and choices related to their ability. Service users who wish to go out alone and take responsibility for some aspects of their daily life are assisted to do so. Service users have a reasonable diet of freshly cooked meals in a home environment. EVIDENCE: Service users attended a variety of day centres and specialist social clubs. A weekly schedule for all service users is on the office wall. Depending on confidence and ability a small number of service users are able to travel on public transport and go out alone locally. Group outings are arranged to local venues on occasions. Some service users had recently been to a local theatre Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 12 to see an Elvis impersonator and Country and Western music. Some service users have contact with family. On the second day of the Inspection the relative of one service users phoned and staff was able to give an update on his/her ‘day’ Some service users do not have frequent contact with family. Service users daily routines have been developed around their weekly schedules. There are weekly routine tasks within the home which staff encourages service users to carry out. The Inspector was informed that service users help choose the main meal for the following day, one service user is involved in the preparation of this. Meals are served at large table in the dining room, which creates a family atmosphere. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 The 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 in their health care and personal care as necessary. There are clear guidelines for staff on this. Medication polices, procedures and induction training are in place for safe administration of medication. EVIDENCE: Service users personal care needs and health needs are recorded in the care plan. Service users at Worcester Road are quite independent but still require different levels of prompting in personal care. Any health care concerns are recorded with a list of dates health care professionals have been seen by service users. A format for an annual health check has been developed, although these had not been completed for service users. MENCAP have a policy and procedure for the safe administration of medication. The administration of homely remedies had not been incorporated into this. All staff had attended training on the safe handling of medication. The information on individual service users medication was good, describing why Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 14 the medication is prescribed and any side effects. The Inspector saw the medication cabinet and Medication Administration record these were in order. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are policies and procedures in place for the protection of vulnerable adults. The staff induction programme is well set out and includes information and exercises for staff to complete, on this subject. The Manager needs to ensure that the complaints procedure is accessible for all service users. EVIDENCE: The complaints procedure for service users is in the Service Users Guide, which was updated in December 2005. This is a good procedure a lists the named CSCI Inspector for the home and contact information. Some service users had a copy of the Guide in their room others did not. There is a separate Complaints Policy and Guidelines for staff in the MENCAP staff manual. Information on whistle blowing, financial protection and abuse prevention is available for staff in the staff manual. A substantial amount of information is available in the staff induction folder on service user protection. The London Borough of Hillingdon Adult Protection Procedure is kept in the home; this includes a flow chart of how to report abuse and the expected outcomes. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 27 28 30 The Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The accommodation offered to service users is homely, comfortable and clean. Two bathrooms require refurbishment to improve the facilities offered to service users. For one service user the facilities in the bathroom are unsuitable and unsafe. EVIDENCE: There is ample communal space in the home for the seven service users. Each service user has their own bedroom, which is individual to their tastes. One service user has partially converted his/her room into an office, office work being his/her favourite pastime. The home is beginning to show signs of wear, although the environment is satisfactory at present consideration will need to be given to decoration in the future. The curtains in the dining room were not fitted to the curtain rail correctly and were hanging loose. The timescale for the requirement for the refurbishment of the two toilet/bathrooms on the first and second floor had not been met again this has Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 17 been a requirement of previous inspection reports. The Manger Designate explained that is the responsibility of the Housing Association, who had been informed but had not responded to meet the timescale set by CSCI. . Plans to refurbish the bathrooms need to be made to improve standards in this area of the home. Quotes to replace the lino in both bathrooms had been sought MENCAP will replace the flooring. In addition to the poor state of the décor and facilities in the bathrooms, there is a health a safety risk for one service user when using the bathroom/toilet. This service user requires a Zimmer frame to walk and the Zimmer frame will not fit through the bathroom door. The service user has to leave the Zimmer outside and then goes into the bathroom and lunges towards the grab rails. The service user has also to grab the shower door whist having a shower. The Inspector was informed that during the day the service user will ask for assistance but will use the toilet alone during the night. Generally, the home was being kept to a high level of cleanliness on the day of the inspection. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the present time the small staff team are able to supervise and promote the independence of service users. Good induction and mandatory training programme is in place for staff. There are organised and robust recruitment procedures for the recruitment of staff. Staff receives supervision on a regular basis. EVIDENCE: Worcester Road has a small staff team of six staff including the Manager Designate. The new Manager commenced in May 2006. One new member of staff had recently joined the team. Staff work alone on shift, the member of staff who works in the evening sleeps on the premises and works the morning shift. Mencap offers an organised induction programme for new staff, which covers information on working with adults with a learning disability and covers other topics relevant to working in a residential home such as health and safety and medication. New staff are expected to complete the induction as part of their probationary period before being offered a permanent contract. Once the induction has been completed staff undertake the foundation course. The package used for induction and foundation is presented as a work book Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 19 whereby staff have to evidence their learning. A Training consultancy provides regular mandatory training for staff. The Inspector was informed that MENCAP have changed their profile and recruitment methods for attracting candidates. Vacancies are advertised at Job Centres and Job Fares. The Registered Manager and a senior member of staff will short list and interview candidates. The life experience of candidates is taken into consideration. The Inspector examined the files of two new members of staff one who had recently started and another who had been recently recruited. Evidence of good recruitment practice was on file, the employment records required under Schedule 2 of the Care Homes Regulations were in place for both applicants. The staff personnel files seen contained supervision records. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 20 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 42 The Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager designate needs to register with CSCI to consolidate her position as registered manager. A Quality Assurance would enable to the Manager Designate to evaluate the quality of care for service users in the home. Policies and procedures are in place for the safety of service users. Good staff training is offered in this area. Despite this, one service user is at risk due to her mobility needs, which cannot be met by the present bathroom facilities. EVIDENCE: Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 21 The new Manager Designate had started in her role approximately two weeks prior to this unannounced inspection. The Manager Designate has experience as working at a Deputy Manager level in another MENCAP residential home for adults with a learning disability. The Manger will be completing her NVQ Level 3 and commencing with the Registered Managers award. At the time of the inspection she in the process of applying for her Criminal Records Bureau check with the Commission for Social Care Inspection. There did not appear to be any written evidence of Quality Assurance Audit in the home. Service users who live in Mencap home do have the opportunity to complete questionnaires with the help of a Manager from another home. The Manager was not a aware if this had happened recently at Worcester Road. MENCAP has in place polices and procedures for staff on health and safety. Health and safety is also covered in the Induction programme. Staff undertake mandatory health and training yearly some staff needed a refresher in food hygiene, first aid and fire safety, arrangements had been made for this. At the time of the inspection one member of staff was new and had come from another MENCAP home, the Manager said she would be asking for this information. The home is unable to meet the safety requirements for one service user. The bathing facilities are totally unsuitable for this service user who has a Zimmer frame, which will not fit into the bathroom. The service user when spoken with by the Inspector did have an insight it her difficulties with this bathroom. This matter must be dealt with promptly. Mobility risk assessment was on file for this service user. Risk assessments are completed for service users and for the home environment. A system for carrying out monthly work place safety inspections is being carried out this is good practice. Hot water outlets are checked and recorded twice monthly although it was not clear if a mechanism was in place for the temperature control of hot water. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 22 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 x 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 3 26 3 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 x 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement Contained in the medication policy must be information on the administration of home remedies. Timescale set at last inspection of 01/03/06 not met The bathrooms on the ground and first floor must be refurbished. CSCI must be informed by the given timescale for action of the plans for refurbishment of the bathrooms. Timescale set at last inspections of 01/12/05 and 01/4/06 not met. 3. YA27 23 (2)(d) The lino must be replaced in the first floor bathroom. Timescale set at the last inspection of 01/04/06 not met. 4. YA39 24 A quality assurance/monitoring system must be put in place to DS0000027070.V288513.R01.S.doc Timescale for action 01/09/06 2. YA27 23 (2)(d) 01/08/06 01/08/06 01/09/06 Worcester Road, 38 Version 5.1 Page 24 review the quality if care. Timescale set at the last inspection of 01/05/06 not met. 5. YA42 13 (4)(a) A mechanism must be put in place to regulate the temperature of the hot water in the bathrooms. Timescale set at the last inspection of 01/05/06 not met. 6 YA42 13(4)(a) To ensure the safety of one service user either the ground floor bathroom must be fully adapted to cater for physical disability (this includes widening the doorway) or alternatively the service user must be assessed and an alternative placement sought. A plan of action must be developed this must be forwarded to CSCI by the date given. 15/07/06 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA19 YA22 YA24 Good Practice Recommendations Health Care Action Plans should be compiled for all service users. The Manager Designate should make sure that the complaints procedure is accessible to all service users. The curtains in the lounge should be replaced or readjusted. Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Worcester Road, 38 DS0000027070.V288513.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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