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Inspection on 19/05/05 for Worcester Road, 38

Also see our care home review for Worcester Road, 38 for more information

This inspection was carried out on 19th May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Worcester Road offers an environment, which is homely and comfortable for service users. The home has been able to retain a core group of staff that have worked there for a number of years. A good programme of day services/work experience is offered to service users.

What has improved since the last inspection?

A book for recording complaints has now been set up. The internal complaints information for service users has been improved and is user friendly.

What the care home could do better:

On the whole the home has the required documents, policies and records in place. However, these should be monitored and reviewed to ensure they comply with the National Minimum Standards. The Service Users Guide should be updated and the Whistle Blowing policy information be reviewed and improved. Staff files should be reviewed to ensure all the necessary staff employment information is in place.

CARE HOME ADULTS 18-65 Worcester Road, 38 Cowley Uxbridge Middlesex UB8 3TH Lead Inspector Susan Woolnough-Singh Unannounced 19 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 38 Worcester Road Address Cowley, Uxbridge, Middlesex UB8 3TH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01895 272794 MENCAP Homes Foundation Holly Southwood Care Home 7 Category(ies) of Learning Disability (7) registration, with number of places Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19/11/04 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 seate 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 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between the hours of 10am and 5pm on the 19th May 2005. Six requirements were made at the last inspection, which took place on 9th August 2004. Five requirements had been met; the timescale for one requirement had not been met. New Era Housing Association had been informed that a requirement for new flooring and redecoration of both bathrooms had been made at the last inspection. The Housing Association had not responded to this. A Manager designate was in post at the time of the inspection. The previous Manager Designate had transferred to another Hillingdon Mencap Home. The Manager Designate and three service users were spoken with during this inspection. What the service does well: What has improved since the last inspection? What they could do better: On the whole the home has the required documents, policies and records in place. However, these should be monitored and reviewed to ensure they comply with the National Minimum Standards. The Service Users Guide should be updated and the Whistle Blowing policy information be reviewed and improved. Staff files should be reviewed to ensure all the necessary staff employment information is in place. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The Service Users Guide is presented in a format suitable for residents. This Guide should be updated to incorporate changes in the home. EVIDENCE: The Key Standards were not assessed at this inspection. However, the Service Users Guide was seen as part of the inspection process. The information in the Guide, on the staff team was out of date. This should be updated once a new House Manager has been appointed. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed. EVIDENCE: Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 standard(s) 12 13 15 16 Service Users at Worcester Road are able to make their own decisions about their routines and activities. A variety of day services were in place and residents appeared to have satisfactory opportunities for activities. EVIDENCE: All of the service users at Worcester Road attend a Day Service on a part time basis; one or two days are spent at home during the week. Three service users attend college for either swimming or singing lessons. One service attends work experience. Service users attend a number of evening clubs for people with a learning disability. One service user goes line dancing. The Manager designate had identified that the shift pattern at weekends needs to be changed to enable service users to be taken out by staff in smaller groups. A small number of residents have family links. The staff endeavour to promote contact with relatives and had sent out invitations to last years Christmas Party. One service user is currently working with the Service Manager on his/her Person Centred Plan which involves making a jigsaw puzzle. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 11 Three service users were spoken with about their routines and activities. Residents spoke about their daily routines. Service users confirmed that they went to college or day centre and were involved in evening activities. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 standard(s) Not assessed EVIDENCE: Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 standard(s) 22 23 There is sufficient information contained in the Induction Training and Operational Policies with regard to Complaints and Whistle blowing to inform staff of their Adult Protection responsibilities. However, the Whistle Blowing procedure was not displayed in a prominent place for staff to see, and information on who could be contacted in the event of a serious incident was not contained in the Whistle Blowing Policy. EVIDENCE: Two Complaints Procedures were seen; both were included in the service users information folders kept in their bedroom. There is one in house procedure which is very clear and informs service users who they need to talk to at Worcester Road. The second procedure contains more information on timescales for investigations and external agencies who may be contacted. There is also information in the Mencap Operational Manual for staff, on Complaints and investigations. A book for recording complaints has been set up since the last inspection. One complaint had been entered. A recommendation was made to the Manager Designate that the format of the record be changed to include complaint, investigation and outcome. Mencap has an Adult Protection Policy and a Whistle Blowing Policy. There is also an Abuse Prevention Policy and Abuse Procedure. The Whistle Blowing Policy did not have any contact names or telephone numbers for staff. This was discussed with the Manager Designate. Staff receive training in relation to Abuse and Whistle Blowing during Induction Training. A section called ‘Value me and protect me is covered in the Induction Training. This assists staff to look as issues of valuing people and protection. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 standard(s) 24 25 27 28 The home is suited to its stated purpose and provides a homely environment for the residents. Apart from the bathrooms, which require refurbishment to provide a better facility for residents, the home is generally well maintained and decorated. EVIDENCE: The home is clean and tidy and offers residents a homely living environment. The shared facilities, a kitchen, lounge and dining room are on the ground floor. The bedrooms are on the second floor. There is a bathroom/toilet on both floors. Three residents bedrooms were seen. These were all kept to the individual style of the resident and were all very different. The timescale for the requirement for the refurbishment of the two toilet/bathrooms on the first and second floor had not been met. The Manger Designate explained that this was the responsibility of the Housing Association, who had been informed but had not responded to meet the timescale set by CSCI. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 34 35 36 The home has a well-established staff team who are know by the residents. The staff team will be further improved when a permanent House Manager is in post and other vacancies can be appointed to. The employment/recruitment files were generally in good order although one piece of required information was not on file. Training is organised well and the courses are designed to assist staff to meet the needs of service users. Although a supervision schedule is in place and all staff have a named supervisor, one to one supervision in the case of one member of staff had lapsed, therefore work with service users was not being officially monitored. EVIDENCE: The home operates on a rota basis. One member of staff is on duty in the morning and two members of staff are on duty in the afternoon/evening. There are two members of staff on at weekends. At the time of the inspection there was a vacancy for a Deputy Manager and one full and part time support worker vacancy. There was a Manager Designate in post and an advert for the recruitment of support workers was due to be issued once the Management posts had been filled. There is a stable staff team at Worcester Road who have all worked at the home for over a period of two years. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 16 Two staff employment files were seen. These were organised well although an application form was missing from one file. In one file there was evidence of the notes taken as part of the assessment of the prospective employee at interview. Two staff training profiles were seen. Staff had received mandatory training such as fire awareness, first aid, basic food hygiene and infection control. The staff had undertaken additional training in dementia, report writing, understating challenging behaviour and conflict management for women. There was a spreadsheet provided by the training company of individual staff training dates for the year. Supervision records were seen; notes of supervision sessions had been made. The content of the notes demonstrated that staff training issues and service users needs had been discussed. One member of staff had not had one to one supervision for a period of a year. Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not assessed EVIDENCE: Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 18 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 x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x 3 3 2 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Worcester Road, 38 Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 19 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 23 Regulation 13 (6) Requirement Timescale for action 1.9.05 2. 27 23 (2)(d) 3. 34 19 (1) (b) 4. 36 18 (2) The Whistle Blowing Procedure must contain inforamtion on who may be contacted in the event of an incident to be reported. New flooring and redecoration 1.12.05 must be planned to take place in both bathrooms. The timescale set at the last inspection for 1.9.04 had not been met. Staff recruitment inforamtion 1.8.05. specified in Schedule 4 of the Care Homes Regualtions must be kept at the home. All staff must receive one to one 1.7.05 recorded supervision at least six times a year. 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 11 22 Good Practice Recommendations The Service Users Guide should be reviewed and updated as required. The format for recording complaints and concerns should be changed to include Complaint - Investigation Outcome. G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 20 Worcester Road, 38 Worcester Road, 38 G61-G10 s27070 Worcester Road v214418 190505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Ground Floor 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. 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