Inspection on 02/04/08 for Dimensions 2 Lindsay Drive

This is the latest available inspection report for this service, carried out on 2nd April 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Dimensions 2 Lindsay Drive 09/02/06

Dimensions 2 Lindsay Drive 01/08/05

Dimensions 2 Lindsay Drive 16/02/05

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 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Adepta 2 Lindsay Drive 2 Lindsay Drive Kenton Middlesex HA3 0TB Lead Inspector Judith Brindle Key Unannounced Inspection 2nd April 2008 08:20 Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 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 Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 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 Older People and 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. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta 2 Lindsay Drive Address 2 Lindsay Drive Kenton Middlesex HA3 0TB 020 8905 0645 020 8903 7607 prokicki@adepta.org.uk www.pentahact.org.uk PentaHact Limited trading as Adepta 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) Manager post vacant Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2) of places Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd and 20th April 2007 Brief Description of the Service: Lindsay Drive is a care home that provides care and, accommodation for five people with learning disabilities. Paddington Churches Housing Association (PCHA) owns the house and PentaHact Limited trading as Adepta provides the care. Accommodation is provided on two floors. There are three bedrooms on the ground floor and two located on the first floor. There is a spacious lounge and large kitchen/dining room on the ground floor of the care home. The property is located on the corner of a quiet road in Kenton and a busy main road. It is approximately 10 minutes walk to the nearest tube station (Kingsbury), and main bus routes are close by. There are shops, restaurants and a range of leisure facilities and other amenities within a few minutes walk or drive from the care home. Documentation/information about the care home is accessible to residents and visitors. The fee contribution paid by residents is documented, and information with regard to the full cost of living in the home can be obtained by contacting the registered owner. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The unannounced inspection took place throughout seven and a half hours during a day in April 2008. There were no vacancies at the time of the inspection. I was pleased to meet and spend a significant part of the inspection with the people living in the home. The manager was present during most of the inspection. The communication needs of the people using the service varied, most of the residents could tell me about their views of the service, one person using the service was able to respond to questions to a limited degree. Observation was a significant tool used in this inspection. Documentation inspected included, the care plans of people using the service, risk assessments, staff training records, staff personnel files, and some policies and procedures. The inspection included a tour of the premises. A person using the service kindly showed me his/her bedroom, and spoke of being ‘happy’ with his/her room. Assessment as to whether the requirements and recommendations from the previous key inspection (3rd and 20th April 2007) had been met also took place during the inspection. 27 National Minimum Standards for Adults, including Key Standards, were inspected during this inspection. Prior to this unannounced key inspection the manager supplied the Commission for Social Care Inspection (CSCI) with a completed Annual Quality Assurance Assessment (AQAA) document. The AQAA is a self- assessment of the service provided by the care home that is carried out by the owner and/or manager. It focuses on the quality of the service and how well outcomes are being met by people using the service. It also includes information on any plans for improvement, and it gives us some numerical information about the service. This document was comprehensively completed. Reference to some aspects of this AQAA record will be documented in this report. Other information received by the Commission for Social Care Inspection about the service since the previous key inspection was also looked at. This included what the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Also relevant Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 6 information from other organisations, and what other people might have told us about the service. The inspector thanks the people living in the care home, staff and the manager for their assistance in the inspection process. What the service does well: What has improved since the last inspection? Redecoration of several areas of the environment has taken place. All but one of the ten inspection requirements from the previous inspection had been met. The manager has developed and improved several systems and procedures within the care home to ensure that a better service is provided to people using the service. Monthly meetings between each person using the service Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 7 and their key worker now take place. General resident meetings have been instigated since the last inspection and provide additional opportunity for people using the service to communicate any ‘concerns’ that they may have. A new staff shift planner has been recently implemented in the home, which clearly documents the duties of staff during each shift. Risk assessments, (which support people using the service to take assessed risk to enable them to be as independent as they are able) have been significantly developed since the previous key inspection. A significant number of policies/procedures were reviewed in 2007. 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. The summary of this inspection report can be made available in other formats on request. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective people using the service have the information that they need to make an informed choice about where to live, and they can feel confident that their needs will be assessed before moving into the care home. EVIDENCE: The statement of purpose, and the service user guide documents include information about the service provided by the care home. There was a requirement from the previous inspection, which included the need to review both documents to ensure that up to date and required information was Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 10 included in these records. The manager updated both documents during the inspection. The manager reported that all the people living in the care home had received a copy of the service user guide. These were accessible in the care plan files of people using the service. The service user guide consists of information about the service, including the accommodation, facilities, and variety of activities, complaints procedure, and included a few pictures. With regard to the communication needs, and reading ability of some people using the service (and possibly prospective residents with similar needs) the manager could continue to review the format (i.e., audio format) of the service user guide with the people using the service, to improve its accessibility to those who have significant, and/or varied communication needs. The care home has an admission procedure. There have been no recent admissions to the care home. All the residents have lived in the care home for several years. The manager informed me that a comprehensive initial assessment is carried out prior to anyone being admitted to the care home, (with participation from the prospective resident, relatives and significant others) so as to ensure that the home can meet the needs of the prospective resident. The manager spoke of the process of assessment, which would include an assessment of the needs of prospective residents carried out by the funding Local Authority. He confirmed that prospective residents are encouraged to visit the home before deciding if they wish to move in, and that these visits varied in number and type in accordance to the needs and wishes of the prospective resident. Visits to the care home form part of the transition process to ensure that prospective residents are able to make an informed choice about where to live, and to ensure that they have the opportunity to meet the people using the service. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service each have a plan of care. There could be some development in the care plans to ensure that it is evident that they are working documents and ‘person centred’, and care plan information is more accessible to people using the service and to staff. People using the service are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. EVIDENCE: Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 12 Two care plan files were inspected. These were ‘bulky’ with a variety of documentation, including some information, which staff should consider archiving, to allow staff (and the resident concerned) to more easily access information about the needs of each person using the service. Development of care plans into shoe evidence of them being in a more ‘person centred’ (i.e. everyday routines and practices are adapted to suit individual residents and improve their daily life so it is meaningful to her/him) format was discussed with the manager. The manager spoke of the current plans to improve the care plans to ensure that they are more ‘person centred’ and working documents. The new care plan format was shown to me during the inspection, and was judged to be an improvement. The care plans inspected included some evidence of staff guidance to ensure that each person using the service receives appropriate care and support from staff to meet their individual needs and preferences. The content of the care plans also included an informative profile of each person using the service. A staff member spoke of her role in developing this record. The care plans recorded evidence of having been reviewed regularly, but it was not always clear how much involvement the person using the service had in their care plan. A resident when asked about their care plan, was not aware of it. The people using the service should have the opportunity to sign their care plan. Health needs, day care/leisure needs, communication needs, personal care needs, personal relationships/social skills, and cultural needs also were included in the care plan documentation. Residents, records, and staff informed me that monthly meetings between each person using the service and their key worker now take place, in which residents can communicate their views and plan activities and other goals for that month. This is positive. A resident knew her/his key worker by name and spoke of them being ‘nice’. Daily’ and night records are completed by staff in regard to the progress of each person living in the care home. Staff were observed to interact with the people using the service in a sensitive and respectful manner during the inspection. It was evident that the care staff had a good understanding of the varied needs of each resident. Choice was offered to the residents frequently, and the people using the service were supported in making decisions. Risk assessments, (which support people using the service to take assessed risk to enable them to be as independent as they are able) have been significantly developed since the previous key inspection. These include areas of potential risk to safety, such as participation in household duties, road safety, and risk to health, which are managed positively to help the people using the service to lead the life that they want. There was evidence that these had been recently reviewed. The manager spoke of plans to further develop the risk assessments to ensure that there is clear ‘step by step’ guidance to meet each person’s assessed risk. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 14, 15, 16, 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 14 The people living in the care home have the opportunity to take part in a variety of preferred activities including those promoting personal development, and are supported to maintain contact with family/significant others. The people living in the care home have their rights respected, and their responsibilities are recognised in their daily lives. Meals are varied and wholesome, and meet cultural/religious needs. EVIDENCE: Staff, records, and people using the service confirmed that they have the opportunity to participate in a variety of preferred activities. Two residents attended a day resource centre during the inspection. They confirmed that they enjoyed this activity and had friends at the centre. Another person using the service kindly informed me that she/he attends this centre three times a week. She/he also told me about the numerous other activities that she enjoyed. These include, regular bingo sessions. She/he informed me that she/he had recently won a prize playing bingo. Other leisure pursuits included attendance of clubs, including the Gateway club, doing tapestry (I was shown some tapestry that was presently being completed by a person using the service). Two residents spoke of the regular music sessions that they particularly enjoyed, and spoke of looking forward to a session due to take place that evening. A resident spoke of his/her love of classical and also jazz music. She/he confirmed that they had the opportunity to listen to music when they wished. A person using the service spoke of regularly accessing the local hairdresser, and of their enjoyment of shopping. Residents spoke of choosing their own clothes and of buying toiletries, and confirmed that they celebrate their birthdays, generally with a party. People using the service spoke of the television programmes that they enjoyed watching, and said that they could choose what to watch. Staff informed me that a resident attends a place of worship with a relative. The home has a list of the dates of Jewish festivals (as well as Christian festivals), to ensure that they can (with support from resident’s relatives and the people using the service) meet the religious needs of residents. Staff informed me that people using the service have taxi cards, and travel passes to enable them to access transport at minimal or no cost. AQAA (Annual Quality Assurance Assessment) documentation informed us that the home aims to develop the number and variety of leisure pursuits for people using the service. The visitor’s record book indicated that there were numerous visitors to the care home. There are no imposed restrictions on visits (unless requested by the resident concerned). People using the service confirmed that they have the opportunity to develop and maintain personal and family relationships. A Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 15 resident spoke of regularly staying with a family member, another resident spoke of enjoying visits to his/her relatives. Residents confirmed that they had not been on holiday in 2007. The care home should support people using the service to take a holiday of their choice. A person using the service spoke of regularly ‘tidying my room’, and of participating in other household duties. The people living in the home were observed to have unrestricted access to communal areas of the home, and their bedrooms. On the morning of the inspection a resident kindly let me into the home by using his/her key (following checking my ID badge, and asking me several questions). Staff spoke of shopping for food once a week and of purchasing (with residents) locally, fresh produce. Fresh fruit was accessible in the care home. A menu was displayed. This was in written format. The manager spoke of plans to improve the format of the menu so that it was more accessible to residents who have difficulty in reading. Meals recorded were judged to be varied, and wholesome, and meet cultural needs. The staff member on duty was knowledgeable of the particular dietary needs of people using the service, and informed me that the residents have the opportunity to plan the menu. Residents informed me that they enjoyed the meals, and chose what they wished to eat. They spoke of enjoying the lunch provided during the inspection. A care plan inspected recorded the particular cultural dietary needs of a person using the service. A resident helped prepare his/her lunch during the inspection. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service have their personal care and healthcare needs met. Systems are in place to ensure that medication is stored and administered safely to people using the service. EVIDENCE: The care plans inspected, recorded evidence of assessment of the personal care and health needs of people using the service. It was evident that residents have the support and care they require to meet their personal care needs. Health needs of people using the service are monitored, and they have Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 17 access to appropriate intervention, care, and treatment from a variety of healthcare professionals, which include the GP, optician, dentist, and chiropodist. A resident spoke of having recently been to a hospital to attend an appointment, another person using the service spoke of having seen a GP recently. Residents’ weight is monitored. Following the inspection the manager supplied the CSCI with recorded evidence that people using the service had each received a moving and handling assessment, with appropriate guidance for staff to follow to ensure that the mobility needs of residents were understood and met by the care home. This was a previous inspection requirement and was judged to have been met. The care home has a medication policy/procedure. The home uses a Monitored Dosage System (MDS) for administration of medication, and all prescribed medication is delivered in blister packs each month. The records were well maintained and I found no errors or omissions. It was noted that staff had not recorded on the medication administration record sheets whether people using the service had any known allergies. A senior member of the care staff recorded this information during the inspection. Records are maintained of any medication received and/or returned to the pharmacist. The home has appropriate medication storage systems, and the manager spoke of the medication training that all staff complete, and of the ongoing monitoring that he carries out to ensure that staff are administering medication safely. Records confirmed that staff had received medication training from a pharmacist, and the manager confirmed that all staff receive ‘in house’ medication training as part of their induction, and that staff only administer medication to people using the service when they are judged to be competent. A staff member spoke of having received medication training. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and handled objectively. The format of the complaints procedure could be developed to improve its accessibility to people using the service. Residents are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints policy/procedure. This is in written format and could be further developed to improve its accessibility to people using the service. This was discussed with the manager, who spoke of his plans to improve the format of this and other documentation. Records are maintained of complaints. Information provided by the manager in the Annual Quality Assurance Assessment (AQAA) is evidence that there has been one complaint within the last twelve months. It was evident that this complaint (and another more recent complaint) had been responded to appropriately in accordance with the company’s procedures and within agreed timescales. Two staff Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 19 confirmed that they were fully aware of the reporting and recording procedures in response to a complaint/concern made from a resident and/or visitor. The manager spoke of the various ways that staff have developed their support to people using the service and others who wished to make a complaint. Two complaints from residents were recorded, and some of the action taken by the manager in response to these were recorded. The manager updated these records during the inspection to ensure that appropriate information about his response, including with the complainant was documented. The manager should ensure that these records are kept up to date. Resident meetings have been instigated since the last inspection and provide additional opportunity for people using the service to communicate any ‘concerns’ that they may have. The home has a protection of vulnerable adults policy/procedure. Accidents and incidents are recorded. It was evident from contact with the manager following the previous inspection that he had knowledge and understanding of the required and appropriate action that needs to be taken in response to a suspicion and/or allegation of abuse. Other staff that spoke with me were also knowledgeable of the action, (including reporting and recording) which they need to take to protect people using the service from abuse. Staff and records informed me that staff had recently received protection of vulnerable adults training. The management of resident’s finances was discussed with staff. People using the service are signatories for their bank/building accounts. Appropriate systems are in place for checking expenditure records and monies. Receipts are obtained for all purchases. Receipts inspected confirmed that residents spent money on a variety of items including toiletries and travel. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,26,and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely, and comfortable, but there are areas of the care home where the décor could be improved. The premises are suitable for the care home’s stated purpose. EVIDENCE: Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 21 The care home is located close to Kingsbury, which has a variety of shops, pubs, restaurants, banks and other amenities. Public transport facilities include train and bus services, which are located a few minutes, walk from the care home. The inspection included a tour of the premises. The home was generally clean, and homely. Staff and people using the service informed me that communal areas of the care home, including the sitting room had been recently redecorated. Residents spoke of liking the décor, and having been involved in choosing the colour. A bedroom has also been redecorated since the previous inspection. There have been other improvements such as replacing some furnishings in the bathrooms and other areas. The manager reported that a referral had been made for an occupational therapist to assess the environment of the care home. I was informed that the carpet in communal areas was to be replaced. This is positive due to it being ‘ruffled’ and fraying in places. The tape that is in place (to minimise the risk of tripping) on the carpet in the doorway of the sitting room should be replaced. The front and rear gardens could be better maintained. Litter located at the front garden area of the home should be tidied up. The bathrooms in the home have areas of paintwork, which are ‘shabby’, and should be repainted, to improve the appearance of the rooms. This was a previous recommendation and is again strongly recommended. The manager spoke of the action that he has taken to endeavour to try and get this work completed. A person using the service kindly showed me his/her bedroom. This was personalised with a number of personal items. The resident spoke of being very happy with the room and informed me that he/she loved all the ornaments that he/she had collected, and had on display in the room. There was a slight unpleasant odour noticed in this room. The manager spoke of his plans to replace the carpet in the room. There needs to be arrangements in place to ensure that there is no noticeable disagreeable odours in the home. The laundry facilities are located away from food storage and food preparation areas. These facilities include an industrial washing machine and dryer. Soap and hand towels were located in the bathrooms/toilets inspected. A staff member was observed to wear protective clothing as and when needed. Records confirmed that staff had received infection control training. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent, supervised and skilled to enable them to carry out their roles and responsibilities to ensure that the needs of people using the service are met. People using the service are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 23 A staff rota was available for inspection. This confirmed that there is generally two staff on duty at all times when the residents are at home. There is a ‘wake night’ staff member on duty at night. I was informed that agency staff are rarely employed, but that ‘bank’ staff (staff employed by the Organisation, work shifts as and when needed in the Organisation’s care homes) work in the care home as and when needed. The manager said that these staff are generally very well known to the people using the service. A new staff shift planner has been recently implemented in the home. This document records staff roles and responsibilities, and residents activities and plans on a daily basis. The staff are experienced and have worked in the care home for sometime. Regular planned staff meetings take place. These are well attended. The manager spoke of the ongoing action that he had taken and plans to carry out to continue to develop and improve the staff teamwork and staff skills. I was informed that there have not been any new staff employed in the home for sometime. The manager confirmed that staff receive an induction that meets Skills for Care Induction Standards and National Minimum Standards. Staff confirmed that they had completed an induction programme on the commencement of their employment. The home has an up to date training plan and individual staff training records are in place. Records confirmed that staff receive statutory training and induction training appropriate for their role and responsibilities. This training includes moving and handling, health and safety, Basic 1st Aid, fire safety training. Care staff spoke of recent risk assessment and ‘person centred planning’ training that they had received. Staff also receive training that is particularly relevant to the care home, which includes training in understanding ‘challenging behaviour’ and diabetes. A staff ‘development day’ had also recently taken place. During which staff had discussed and agreed some new ways of working and put in place goals to continue to improve and develop the service for residents. This is positive. AQAA documentation informed me that two out of seven permanent care staff had achieved an NVQ (National Vocational Qualification) in care at level 2 or above, and that one staff member was working towards obtaining this qualification. I was informed by the manager and care staff that they were in the process of applying for this training course and/or for an NVQ level 3. This is positive. All care staff should have the opportunity to achieve this qualification to ensure that a competent staff team, which maintains and develops its skills, supports people using the service. The home has a recruitment and selection policy/procedure. Three staff personnel files were inspected. All had evidence that a satisfactory enhanced Criminal Record (a check to obtain information about any criminal offences that may have been carried out by the applicant) had been obtained. There was evidence that appropriate recruitment and selection checks had been carried out, but in two files there was not recorded evidence that references had been obtained. I was informed that the process of recruitment and Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 24 selection of staff is carried out by the human resource department, and that original documents are held at the organisation’s office. The manager had completed a checklist of a record of him verifying some of the required recruitment documentation. He spoke of being in the process of completing this task, and of reviewing and improving the staff personnel files. I was informed that people using the service participate to some extent in the recruitment and selection of new staff, and that there were plans to ensure that this is further developed. This is positive. Staff confirmed that they receive the staff supervision that they need to carry out their jobs. A record of three staff 1-1 supervisions was inspected. It was evident that the frequency of these vary, and though all three staff had had recent supervision, they had not received six staff supervisions in the previous twelve months. The manager spoke of times when for some reason the supervision meeting had to be cancelled. The reasons for this should be documented. The manager informed me that he now has to work two shifts, when he is not supernumerary and that the assistant manager now generally does not have any shifts when she is not supernumerary, so the manager is presently carrying out all staff supervisions. This I was informed makes it difficult for him (and previously, the assistant manager) to carry out staff supervision as when management staff are working ‘on shift’ they are meeting the needs of people using the service, and are having to carry out various duties including household responsibilities. The organisation should review this situation to ensure that management staff have time to carry out the numerous management duties needed when running the care home. Records confirmed that staff had recently had an appraisal. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37,39,41and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 26 Health and safety and welfare of people using the service is promoted and protected by a competent manager who is keen to achieve positive outcomes for residents and staff. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home. EVIDENCE: The manager has managed the care home for approximately eighteen months. He is qualified, competent and experienced to run the care home. He has NVQ (National Vocational Qualification) level 4 in management and care. The manager, and records confirmed that he undertakes periodic training and development to maintain and update his knowledge, skills and competence. He spoke of having recently received training with regard to meeting the ethnic and diversity needs of people using the service, and that he had plans for other staff to receive this training. The manager has not yet registered with the Commission for Social Care Inspection (CSCI). He confirmed that he had commenced the process of registration, having obtained a satisfactory Criminal Record Bureau check, and would shortly be supplying the CSCI with completed registration documents. It was evident that the manager has worked hard since the previous key inspection (April 2007) to improve and develop the service provided to people using the service. He has put in place a number of systems to improve the quality of the service, and to develop and improve staff teamwork. Policies and procedures are implemented in accordance with organisational policies and relevant regulations. Effective quality assurance, and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home. A review of the service provided by the care home to people using the service is carried out annually, and includes obtaining views from residents, staff and others about the care home. I was shown a record of a recent review that had taken place. This confirmed that views of residents had been sought and that an action plan had been put in place to respond to the views and to instigate improvements to the service provided to them. It was noted in the minutes of resident meetings that the people using the service were confident in communicating their views and wishes. The manager reported that the Organisation had recently achieved Investors in People Award. Visits by the owner (or representative of the owner) to monitor the quality of the service take place, but it was not evident that these occur monthly. The last record of a visit was 31/01/08 and prior to that, I was informed that a visit was carried out in July 2007. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 27 Records required by regulation for the protection of people using the service and for the effective running of the business are maintained, and up to date. The manager confirmed that he planned to enable residents to be more involved in their records, and to develop the format of documentation to improve their accessibility to people using the service. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. There were no obvious health and safety issues apparent during the inspection The AQAA documentation informed me that health and safety policies and procedures are in place and are reviewed, and that regular health and safety checks, including required equipment checks are carried out. The home has a recorded health and safety risk assessment. The benefit of including health and safety and fire safety issues in each future staff meeting was discussed with the manager. The manager spoke of there having been some concern with regard to the lighting system, with light bulbs not lasting as long as previously. It was noted that the electrical installation check was due on the 3rd April 08. The manager confirmed that he would request that this check was carried out promptly. Fire drills and weekly checks of fire system take place, and the care home has an up to date fire risk assessment. There should be a record of the names of all those (including people who use the service) who take part in the fire drills, and a record be made of any issues that might be apparent with regard to response from people using the service to the fire alarm. Some doors in the care home were propped open to allow easy access for residents and others. The manager confirmed that the need to close these doors was recorded in the fire risk assessment and that safe door opening devises were to be fitted. Fridge/freezer temperatures and hot water temperatures are monitored closely. During the inspection, the manager completed risk assessments with regard to the uncovered radiators in the bedrooms of two residents. This met a previous requirement. Accidents and action taken to prevent further occurrence of accidents/incidents are recorded. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 28 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 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 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 3 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Adepta 2 Lindsay Drive Score 3 3 3 X DS0000062633.V361100.R01.S.doc Version 5.2 Page 29 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 Standard YA30 Regulation 16 (2)(k) Requirement There needs to be arrangements in place to ensure that there is no noticeable disagreeable odours in the care home. The manager of the care home needs to be registered with the Commission for Social Care Inspection (CSCI). Timescale 01/10/07 not met Visits to the care home by the registered provider (or representative) shall take place at least once a month and shall be unannounced. This is to ensure that the owner closely monitors the quality of the service provided to people using the service. Timescale for action 01/07/08 2 YA37 CSA 2000Part ll (11)(1) 26(3) 01/08/08 3 YA39 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 30 No. 1 2 Refer to Standard YA1 YA6 Good Practice Recommendations The format of the service user guide could be further developed i.e. audio, to improve its accessibility to those people using the service who cannot read. There could be further development in the ‘person centred care planning’ approach. This should include more evidence of involvement from residents in their care plans. There could be review of the format of the care plan including more pictorial format. To ensure improved accessibility of information to people using the service. The people using the service should have the opportunity to sign their care plan The care home should support people using the service to take a holiday of their choice. The format of the menu could be improved so that it was more accessible to residents who have difficulty in reading. The manager should ensure that complaints records are kept up to date, and that the format of the complaints procedure is further developed to improve its accessibility to all the people using the service. The tape that is in place (to minimise the risk of tripping) on the carpet in the doorway of the sitting room should be replaced. The sitting room carpet could also be replaced. The front and rear gardens could be better maintained. Litter located at the front garden area of the home should be tidied up. In an upstairs bathroom (at the top of the stairs) the bath panel is ‘shabby’ and should be replaced, and the walls repainted. The other bathrooms bathroom should be redecorated. All care staff should have the opportunity to achieve an NVQ (National Vocational Qualification) level 2 or above in care, to ensure that a competent staff team, which maintains and develops its skills, supports people using the service. All staff should receive regular recorded staff supervision meetings at least six times a year to ensure that they are supported in meeting the needs of people using the service. Management staff should be have sufficient supernumerary time to carry out these meetings. It should be recorded when a staff supervision meeting is cancelled/postponed. The format of records of particular relevance to people DS0000062633.V361100.R01.S.doc Version 5.2 Page 31 3 4 5 YA14 YA17 YA22 6 YA24 7 YA24 8 YA32 9 YA36 10 YA41 Adepta 2 Lindsay Drive 11 YA42 using the service should be further developed and improved. Staff personnel files could be improved. The registered person should record the names of all staff and residents who participate in a fire drill, to ensure that it is evident that they receive ‘training’ with regards to responding to the fire drill. Door safety opening devices should be fitted to doors that need to be kept open during the day to allow people using the service to move freely within the care home. Adepta 2 Lindsay Drive DS0000062633.V361100.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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