Inspection on 20/10/05 for Worcester Road, 38

This inspection was carried out on 20th October 2005.

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 12/05/06

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

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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 20th October 2005 10:00 Worcester Road, 38 DS0000027070.V258196.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 Worcester Road, 38 DS0000027070.V258196.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. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 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) Royal Mencap (Housing & Support Services) Holly Southwood Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one service user, currently living there, who is aged above 65 years. 19th May 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.V258196.R01.S.doc Version 5.0 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 have now been inspected for the inspection year 2005/6. 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 one service user privately and spent time in the dining room with another service user, whilst tea was being cooked. Generally on this occasion service users who were asked did not wish to meet with the Inspector. What the service does well: What has improved since the last inspection? What they could do better: At the present time the toilets and bathrooms are in urgent need of refurbishment to improve standards for service users in this area. A formal quality assurance system would enable to the Manager to closely monitor all areas of management and administration in the home. Worcester Road, 38 DS0000027070.V258196.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. Worcester Road, 38 DS0000027070.V258196.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 Worcester Road, 38 DS0000027070.V258196.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): 2 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. Worcester Road, 38 DS0000027070.V258196.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): 6, 7 and 9 Service users have individual plans in place, which reflect their routines and daily choices. EVIDENCE: All service users have an individual care plan and staff at the home have also initiated person centred plans with two service users. One service user was able to show the Inspector his/her person centred plan in the form of word and photographs. The Care Plans are satisfactory and cover service user likes and dislikes and daily care needs. Attention needs to be given to the review of care plans as one care plan was dated February 2004. The care plan should be reviewed at least every six months. 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. The Inspector sampled three service user files to gain the above information. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 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): 17 Service users have a reasonable diet of freshly cooked meals in a homely environment. EVIDENCE: The Inspector examined the menu; this reflected a varied diet of main meals although vegetables did not appear to be on the menu every day. The Inspector was informed that service users help choose the main meal for the following day, one service users is involved in the preparation. Meals are served at large table in the dining room, which creates a family atmosphere. Service users and staff usually eat out on Saturday and Sundays. During the week service users either take lunch money or packed lunch to their day provision. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 11 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 Service users are supported in their health care and personal care as necessary. There are clear guidelines for staff on this. 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 when service users have been seen by health care professionals. One service user had a health care action plan. It is to be recommended that these be developed for all 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 the medication is prescribed and any side effects. One service user has PRN medication which he/she self medicates. Staff make a record when this is given to him/her. The Inspector saw the medication cabinet this was in order. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 12 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): 23 The key standards have now been met. EVIDENCE: The key standards were assessed at the last inspection. A requirement was made for organisational contact details to be inserted into the Mencap Whistle Blowing Policy this has now been done. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 13 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): 27 and 30 The home is suited to its stated purpose and provides a homely environment for the service users, apart from the bathrooms, which require refurbishment to provide a better facility. The home is generally well maintained and decorated. EVIDENCE: 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 is the responsibility of the Housing Association, who had been informed but had not responded to meet the timescale set by CSCI. The area outside of the first floor toilet had a noticable odour; this may be due to the stained lino in the toilet. Plans to be refurbish the toilet and bathrooms need to be made to improve standards in this area of the home. Generally, the home was being kept to a high level of cleanliness on the day of the inspection. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 14 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): 34 The key standards have now been met. EVIDENCE: The key standards were assessed at the last inspection. A requirement was made at the last inspection that staff recruitment information as specified in Schedule 4 of the Care Homes Regulations should be kept in the home. This standard is now being met. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 15 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): 39 and 42 A Quality Assurance system must be put in place to enable the Manager to formally monitor and evaluate the quality of care in the home. Health and Safety monitoring was satisfactory, however systems need to be put in place for the safety of hot water for service users. EVIDENCE: The Inspector was able to see a very brief business plan for 2005/6 the focus of which was staff training. There did not appear to be a specific Quality Assurance monitoring tool, although the inspector was informed that a Registered Manager from another Mencap home had been completing questionnaires with service users. Health and Safety training for staff takes place on a regular basis, and external training company is employed to do this. Working safely is also covered in staff induction training. A Mencap health and safety policy is available in the home. Fire alarm systems and emergency lighting had been recently checked. Electrical testing had been carried out in April 2004. Personal health and safety for service users is covered by individual risk assessment. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 16 The Inspector was informed that water temperature in the home was not regulated. An arrangement had been made for thermostatic valves to be fitted. This had not been done at the time of the inspection. The water system had not been tested for Legionella. Worcester Road, 38 DS0000027070.V258196.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 3 x x x Standard No 22 23 Score x 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x 2 x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Worcester Road, 38 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000027070.V258196.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 YA20 Regulation 13 (2) Requirement Contained in the medication policy must be information on the administration of home remedies. New flooring and redecoration must be planned to take place in both bathrooms. The timescale set at the last inspection for 1.12.04 was not due to be met. The lino must be replaced in the first floor bathroom. A quality assurance/monitoring system must be put in place to review the qulaity if care. A mechanism must be put in place to regulate the temperature of the hot water in the bathrooms. The water system must be tested to eliminate the risk of Legionellla. Timescale for action 01/03/06 2 YA27 23 (2)(d) 01/04/06 3 4 6 YA27 YA39 YA42 23 (2)(d) 24 13 (4)(a) 01/04/06 01/05/06 01/05/06 7 YA42 13(4)(a) 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 19 No. 1 2 Refer to Standard 6 19 Good Practice Recommendations Service user care plans should be reviewed at least every six months. All service users should have a health action plan. Worcester Road, 38 DS0000027070.V258196.R01.S.doc Version 5.0 Page 20 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. 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