Inspection on 15/08/05 for Wray Court (3)

This inspection was carried out on 15th August 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wray Court (3) 31/10/06

Wray Court (3) 05/12/05

Wray Court (3) 18/01/05

Wray Court (3) 27/07/04

Wray Court (3) 09/03/04

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Wray Court 3 Wray Court London N4 3QS Lead Inspector Beverley Brewer Unannounced 15/8/05 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. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Wray Court Address 3 Wray Court, London, N4 3QS 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) 020 7281 4464 Maggie.paris@islington.gov.uk London Borough of Islington Mr. Andrew Washington Care Home 6 Category(ies) of PD Physical Disability (6), LD Learning Disability registration, with number (6) of places Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No conditions Date of last inspection 18th January 2005 Brief Description of the Service: Wray Court offers a respite care service to five service users with learning and/or physical disabilities at any one time. The home also provides one emergency placement, which is used for extra respite if not in use. Wray Court is owned by the London Borough of Islington. Accommodation is offered in a bungalow type building. All of the bedrooms are single. Bedroom furnishings are provided to meet the needs of service users accommodated at any one time, for example one user may not cope with chairs and wardrobe in the room. Placements are offered at Wray court in a planned way following referral, assessment and a care plan decided by a central panel. The home currently provides respite services to approximately 30 people. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection within the new inspection schedule from 1st April 2005 to 31st March 2006. The inspection took place during a weekday. The majority of the time was spent speaking with the manager and members of the staff team. Service users were consulted as part of the inspection. The remainder of time was spent examining records, touring the premises and observing the interaction between staff and service users. What the service does well: What has improved since the last inspection? What they could do better: Senior managers should make every effort to fill the numerous staff vacancies. The Care Manager should prioritise developing individual training profiles for Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 6 staff and appropriate management supervision. Individual plans of care must be provided even when an emergency placement is made. A record of complaints must be maintained and all notifiable occurrences reported without delay to the CSCI. All matters highlighted in the recent fire officers report will need to be addressed. Wray Court requires some internal redecoration. 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. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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) 2 Service users are assessed in a planned way prior to admission. EVIDENCE: All prospective service users are assessed via the care management system prior to admission. Each service user is allocated a set number of respite days depending on their individual needs. The extent of consultation with service users varies according to the individual’s abilities and insight. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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) 6, 7 & 9 There is a clear care planning system in place that involves the service user and provides staff with sufficient information to meet the needs of service users who are placed for planned respite. There is a lack of a care planning process for emergency placements. Whilst staying at Wray Court service users carry on with their usual routines with staff support as required. EVIDENCE: The quality of recorded information for respite clients was good with each service user having an individual plan of care, risk assessment and Care Programme Approach care plan if appropriate. At the time of this inspection one service user had been placed at Wray Court on an emergency basis for a number of weeks. This individual did not have a plan of care or assessment on file. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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, 16 & 17. Standard15 is not applicable to this service. Service users are supported to carry on with their usual activities whilst staying at this respite centre. Service users rights and responsibilities appear well respected. EVIDENCE: There is significant evidence that service users are supported by staff to maintain their usual lifestyles whilst staying at Wray Court. Many service users are supported by external agencies and this continues during respite. There is good documentation outlining who is responsible for what. An examination of menus and conversations with service users indicates that service users are satisfied with the quality of the food provided. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 & 20. Arrangements are in place to meet the health and welfare needs of the service users. EVIDENCE: Plans of care give a lot of information regarding the personal support required by service users. The procedure for the administration of medication is satisfactory. At the time of this inspection all service users had been assessed as not being able to administer their own medication. Lockable facilities are not provided in individual bedrooms. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 standard(s) 22 & 23 There is a lack of appropriate complaints recording. Senior staff are not aware of their legal responsibilities to report occurrences as outlined in Regulation 37. There is an adult protection policy and procedure in place. EVIDENCE: On the day of the inspection a record of complaints was not available. The Care Manager verbally reported two complaints to the Inspector. Two adult protection cases had not been reported to the Commission for Social Care Inspection as required by Regulation 37. Senior staff were not aware of their legal responsibilities. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 standard(s) 24 & 30 Physical standards at Wray Court are satisfactory. The building is comfortable and safe. The building is clean and hygienic. Internal redecoration will be necessary within the next financial year. EVIDENCE: All parts of the home were viewed by the Inspector. Wray Court was found to be homely and comfortable. Redecoration will be necessary within the next 18 months as some areas were starting to become shabby. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 & 36 There are a number of staff vacancies resulting in the use of many temporary staff. Staff are not supervised regularly. Excellent training opportunities are available for permanent staff although it is not clear what management arrangements are in place to ensure that staff take advantage of these training opportunities. EVIDENCE: Despite requirements made in previous inspections there are still a number of staff vacancies that are being filled by temporary staff. The Care Manager reported difficulties in recruiting staff in this area despite recent national advertisements. Staff are still not being supervised on a regular basis. There are excellent training opportunities available for staff but individual training profiles are not provided so that it is difficult to determine whether staff avail themselves of these opportunities. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 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 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) 39 & 42 Service users have opportunities to comment on the service as a whole and on their individual care. The health and safety of service users is generally well protected however a recent fire safety report has raised some concerns. EVIDENCE: An annual service user survey is undertaken. Service users reported that staff consulted them on matters affecting them. Health and safety matters have improved since the last inspection. Remedial action has taken place on the water system and the electrical fixed installation. A fire safety audit inspection report of July 2005 has highlighted a number of matters that require attention. Fire drills are occurring on a regular basis. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x N/A 3 3 Standard No 31 32 33 34 35 36 Score x x 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Wray Court Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA6 YA22 Regulation 15 22 & 37 Requirement The registered person must ensure that every service user has an individual plan of care. The registered person must ensure that a record of complaints is maintained. All occurences as outlined in Regulation 37 must be reported without delay. The registered person must ensure that the home is redecorated. The registered provider is required to recruit to staff vacancies. This requirement is being restated. The registered person must provide individual training profiles for staff. The registered provider must ensure that management supervision occurs regularly. This requirement is being restated. The registered provider must ensure that all matters highlighted in the fire safety audit inspection report are addressed within the agreed timescales. Timescale for action 30/9/05 30/9/05 3. 4. YA24 YA33 23 18 31/3/07 31/12/05 5. 6. YA35 YA36 18 18 31/12/05 30/9/05 7. YA42 23(4) Within the agreed LFEPA timescales. Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 18 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. Refer to Standard Good Practice Recommendations Wray Court g58 s31155 Wray v192817 150805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Centro 4 20-23 Mandela Street Camden Town, London NW1 0DW 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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