Inspection on 22/07/05 for 4 College Road

This inspection was carried out on 22nd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

4 College Road 23/08/07

4 College Road 19/06/06

4 College Road 10/02/06

4 College Road 04/11/05

4 College Road 31/01/05

4 College Road 05/04/04

Similar services:

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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 08/07/2008.

CARE HOME ADULTS 18-65 Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL Lead Inspector Julie Schofield Unannounced 22 July 2005 9.00am 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. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 4 College Road Address 4 College Road Wembley Middlesex HA9 8RL 020 8908 6894 020 8900 9633 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) Striving For Independence Group Dorothy Pinnock Care Home 3 Category(ies) of LD 3 registration, with number of places Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31 January 2005 Brief Description of the Service: This home is one of a group of 3 homes, in Brent and in Harrow, which are owned by the proprietor’s company (SFI – Striving for Independence). The home provides a service for 3 adults with learning disabilities. At the time of the inspection there were no vacancies. The house is semi-detached and the property consists of two floors. The service users’ bedrooms are situated on the first floor, with bathing and toilet facilities on both floors. There is an open plan dining area and lounge and there is a lovely garden at the rear of the property. The proprietor is also the registered Care Manager. There is a close connection between the homes in the group and one resident from College Road attends the day centre, which is in the grounds of the other home in Wembley. Another resident works in this day centre on a part time basis. Residents from each of the homes are able to take part in joint activities arranged by the company that take place on a Wednesday, during the summer, and at weekends. College Road is a quiet residential turning close to Preston Hill and within reach of both bus and underground services. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Friday morning in July 2005 and lasted for 4 hours 15 minutes. The manager was not on duty at the start of the inspection but travelled from the company’s head office to take part. The Inspector met each of the 3 residents. The member of staff on duty and 2 of the 3 residents took part in the inspection and the Inspector would like to thank them for their comments. A site visit took place and certain records were inspected. What the service does well: What has improved since the last inspection? Since the last announced inspection a raised patio area has been created at the end of the garden, in addition to the patio area immediately outside the Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 6 French windows. Work has commenced on the front garden and a new layout is being created, which includes a paved area and round floor beds. 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. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 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 Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 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) These standards were not inspected as the residents have lived in the home for approximately 10 years, which is prior to the setting up of the CSCI and the NCSC. EVIDENCE: Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 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, 9 Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed. To maintain the provision of appropriate support to residents the agreements contained in the minutes of review meetings need to be on file, for reference. Case file management contributes towards efficient systems of working. Staff support residents to take responsible risks so that residents can enjoy an independent lifestyle. Risk assessments must be current to ensure that they meet the needs of residents. EVIDENCE: The manager said that the case files of residents were being updated at head office and arranged for a member of staff to bring them to the home during the visit so that they could be inspected. When they were inspected it was noted that they contained information dating back several years and that information on the same subject appeared in different sections of the file. Case files contained a care plan and evidence of regular reviews of the care plan and placement. The names of those attending the review meeting need Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 10 to be included in the minutes. However there were no minutes on 2 files for the most recent case reviews, which had involved the local authority. A comprehensive risk assessment form was present on each file but these were dated 2003 or early 2004. There was no record of these being reviewed on a regular basis. Risk assessments were tailored to the individual needs of service users and included short, medium and long term goals. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 17 Residents have access to day centres, college, resource centres and employment, which provide an opportunity to develop their social and communication skills. Taking part in activities gives residents the opportunity to become more independent and to enjoy an interesting and stimulating lifestyle. The support of staff enables residents to maintain family contact. Residents have a varied and balanced diet, with dishes to satisfy cultural needs. EVIDENCE: One of the residents said that they still worked part time, 2 days per week, and that in September they would be starting a college course (numeracy and computer studies) for 2 days per week. At the moment they also helped out in the company’s day centre. The other residents attend a day centre each day and one resident said that they enjoyed this as they chatted and had drinks there. The manager said that Makaton sessions took place in the company’s day centre as staff had previously attended a training course. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 12 A resident said that they had voted at the last election. The manager said that one resident goes to church each week and is escorted by a member of staff. Residents use community facilities including shops, pubs, restaurants, parks etc. They use public transport and the home has access to the company’s minibus. One of the residents said that had been to Alton Towers. A resident said that they went to discos. Each Wednesday the company arranged an outing and a resident said that they had been on a shopping trip, had been to the seaside and had been to the park. The member of staff confirmed that it was part of her duties to accompany and support residents in the community and said that at the weekend they had gone out shopping and had had a pub lunch. Annual holidays are arranged for the residents and a resident confirmed that they enjoyed taking part in these. A resident confirmed that they kept in touch with their family and that they visited a family member and the family member visited them at the home. They said that the staff on duty made visitors to the home welcome. There is a 3-week menu cycle in use in the home. A menu was on display in the kitchen and it demonstrated a varied and balanced diet. The member of staff on duty, who had been on duty the previous evening, confirmed that she had asked residents whether the dish on the menu about to be prepared met their wishes. Last night one resident had requested an alternative, which had been served. The records of meals served to individual residents on a daily basis were available for inspection. These demonstrated that residents exercised choice. One of the residents is African-Caribbean and they said that West Indian food is prepared in the home. A resident is diabetic and the member of staff described how the menu was adapted to meet his needs. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 Residents’ health care needs are met through access to health care services in the community. Records of this need to be up to date so that monitoring can help identify when they are next due. Supporting residents to take their prescribed medication helps the residents to maintain a healthy lifestyle. EVIDENCE: Residents’ case files were inspected and these demonstrated access to health care facilities in the community. There was a record of out patient appointments at the hospital and the manager said that a member of staff escorted the resident, as necessary. A record is kept of appointments with the optician, dentist and chiropodist. However the list on one file needed updating, as an appointment earlier in the year had not been recorded. Routine screening e.g. blood tests had taken place and residents had the opportunity to have a flu jab. The storage of medication was safe and secure. Dosette boxes had been appropriately administered prior to the inspection. Records were up to date and complete. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 14 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 complaints policy in place to protect the rights of residents and 1 of the residents is aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. Financial records must be kept up to date. EVIDENCE: A complaints procedure is in place in the home although only 1 resident would be able to use this without support. The manager said that no complaints have been recorded since the last announced inspection. One of the residents said that they were happy with the quality of the service provided and that they did not have any complaints. They were confident that if they had any concerns or complaints that they would speak to the manager. An Adult Protection procedure is in place in the home. The manager said that no allegations or incidents of abuse have been recorded since the last announced inspection. She confirmed that the staff team has received training in the protection of vulnerable adults. There was an attendance certificate for the training course in the staff file inspected. The manager also said that the home does not practice restraint. There are policies and procedures in place for handling residents’ monies and for gifts and gratuities. However, the filing of monthly bank statements had lapsed on one case file and the ones that were present were filed in different sections of the case file. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30 Residents enjoy a comfortable and homely environment with pleasant communal facilities. Single bedrooms provide residents with privacy and a room sufficient in size in which to relax. Residents live in a home where standards of cleanliness are good and where bathing and toilet facilities are appropriately placed. EVIDENCE: Work was taking place on the garden at the front of the house and an attractive area of paving, flower borders and beds was being created. A site inspection took place and the home was clean and comfortably furnished, providing a homely environment. Each service user has their own single bedroom, with a wash hand basin. Rooms are all a minimum of 10 square metres. They are comfortable and provide the resident with private space, in which to relax. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 16 The bedrooms are situated on the first floor and on this floor there is a bathroom, with a separate toilet adjacent. There is also a shower room, including a toilet, on the ground floor. There is an open plan lounge and dining area, which is sufficient in size for the number of residents. There are patio doors leading to a large, pleasant garden, which has a patio area immediately outside the doors and a raised patio area at the end of the garden. The staff notice board has been moved from the lounge area to the office and this area now has a more “homely” atmosphere. However the picture placed where the notice used to be does not completely cover the area and some redecoration is needed. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 17 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) 32, 33, 34, 36 Residents benefit from staff that have the knowledge and understanding of the needs of the client group and the home continues to support staff undertaking NVQ training. The rota demonstrated that there were sufficient staff on duty to support the residents but it is important that the total number of hours worked for the company, whether in College Road or elsewhere, is recorded. A recruitment process, which includes checks on the “fitness” of staff, protects the welfare of the residents and the home must ensure that new staff have a POVA check. Individual supervision sessions enhances the overall support available to staff and is an opportunity to encourage personal development. EVIDENCE: The member of staff said that they had finished the NVQ level 2 training course and was waiting for their portfolio to be assessed. She confirmed that she had undertaken training in safe working practice topics and in learning disabilities and challenging behaviour. The manager discussed the qualifications of the other members of the staff team and confirmed that one member had completed their NVQ level 3 training and another member of staff was currently undertaking level 3 training. A copy of the rota was made available for inspection. The member of staff said that she worked some shifts at the day centre and worked in the other homes. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 18 The rota listed a minimum of 1 member of staff on duty in the home, when residents are present. If residents need or wish to return to College Road during the day, Monday to Friday, there is a contact telephone number and arrangements in place to provide staff cover. At night there is a member of staff sleeping in but on call. One new member of staff has been recruited since the last announced inspection and their staff file was inspected. It contained an application form, which demonstrated previous experience with the client group. It also contained 2 satisfactory references, an enhanced CRB disclosure (but this did not have a POVA check because the disclosure was undertaken in 2003) and proof of identity. The member of staff said that staff meetings took place on a monthly basis and staff working in each of the homes attended. The manager said that within the staff meeting there is a “mini training session” and that the last meeting had included a session on “Behavioural Issues”. In addition to general staff meetings there is a monthly house meeting where staff working at College Road attended. She said that she was given individual supervision sessions on a monthly basis and that her annual appraisal had taken place earlier this year. Staff are encouraged to raise ideas and suggestions and meetings and she said that staff had been asked for their suggestions for activities in the day centre. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 19 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) 42, 43 The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents. Insurance cover protects the welfare of residents, staff and visitors to the home and the home needs to display a valid certificate. EVIDENCE: The member of staff confirmed that they had undertaken training in first aid, food hygiene, manual handling, infection control and fire safety. Certificates for servicing the fire precautionary systems, landlords gas safety record etc were inspected. It was noted that these were up to date. An insurance certificate was on display in the home and as it was valid for the period 22/6/04 to 21/6/05 it was out of date. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 2 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 2 2 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Striving For Independence Group Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 2 G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 21 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 6 Regulation 12.1 Requirement That when case files are removed from the home, arrangments are made for the day to day routines of residents and guidelines for staff on how to support residents to be recorded and kept in the home, available for reference by staff. That there is a record of the review of risk assessments included in the residents case file. That the record of bank statements kept on the residents case file is up to date and complete. That the patch left where the notice board has been removed is made good and redecorated. That 50 of staff achieve an NVQ level 2 or 3 qualification. Timescale for action 01 October 2005 and onwards. 2. 9 13.4 01 December 2005 01 October 2005 3. 23 17.1S4.9 4. 5. 6. 28 32 33 23.2 18.1 18.1 7. 34 19.4 01 December 2005 31 December 2005 That a record is kept on the rota 01 October of the total hours to be worked 2005 and by the member of staff, including onwards hours worked in the companys other homes or day centre That when new staff are 01 October employed the home obtains a 2005 and satisfactory enhanced CRB onwards disclosure, which includes a G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 22 Striving For Independence Group POVA check. 8. 43 25.2 That a copy of a valid employers liability insurance certificate is forwarded to the CSCI. 01 October 2005 and onwards RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 6 6 6 6 19 Good Practice Recommendations That a process of archiving certain documents dated prior to 2004 is carried out with the residents case files. That documents relating to the same subject are placed in the same section in the residents case file. That the names of persons attending the review meetings are recorded in the minutes. That the placing authorities are contacted for a copy of the minutes of the most recent review meeting for the resident and that these are placed on file The the record kept on the residents case file of health care appointments is kept up to date. Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Striving For Independence Group G62-G11 S17436 4 College Road v227593 220705 Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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