CARE HOME ADULTS 18-65
4 College Road Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL Lead Inspector
Julie Schofield Unannounced Inspection 4th November 2005 08:00 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 4 College Road Address Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL 020 8908 6894 020 8900 9633 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) Striving For Independence Group Homes Mrs Dorothy Pinnock Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Temporary variation agreed for one named individual (MH) aged 65 years for the duration of his stay, subject to regular reviews. 22nd July 2005 Date of last inspection 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 proprietors 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. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was in response to an anonymous complaint about SFI, the company, where the complainant raised concerns about managerial presence in the homes, recruitment procedures, privacy and residents’ finances. The inspection started at 8.00 am in College Road and later the Inspector and manager went to the head office at Pettsgrove Ave to inspect staff records and some records of residents’ finances. The inspection finished at 1.30pm . The Inspector would like to thank the manager, staff and residents who took part in the inspection. What the service does well: What has improved since the last inspection?
The work on the garden at the front of the house has been completed and this provides an attractive feature for the home. There is a paved area and border and beds planted with shrubs. There are now handrails on either side of the path from the garden gate to the front door. The previous inspection was in July 2005 and the timescales for some of the statutory requirements identified in the report have not yet expired. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 6 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
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the standards were inspected during this inspection. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Appropriate support with the handling of their money protects the rights of the residents and financial records for each resident must be available for inspection to demonstrate its provision. The home must respond to changes affecting the payment of benefits promptly so that any financial records clearly show what money belongs to the resident. EVIDENCE: The manager said that she was the appointee for each of the residents. During an inspection of residents’ financial records it was noted that the money belonging to Resident A was in Resident B’s tin and the money belonging to Resident B was in the tin belonging to Resident A. However the cash amounts corresponded to the balances in the record books. Receipts for purchases and items of expenditure were kept with the record books although receipts had not been filed away after the end of the current calendar month. The record books were up to date and contained running totals. The savings account book was not available for one of the 3 residents. The manager said that the accounts for the residents where benefits were credited contained some money belonging to SFI, as the client had not made their contribution to the fees. This was because the company’s accountant had not produced bills, since the change to the payment of benefits in April 2005. She confirmed that the
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 11 procedure for handling residents’ finances has not been amended to reflect the changes in how benefits are paid to residents. During the previous inspection a requirement was made that there is to be a record of the review of risk assessments included in the residents case file. The timescale for implementation had not expired and so this was not inspected. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 17 Residents have access to day centres and to employment and this provides them with opportunities to develop their social and independent living skills. Residents have a varied and balanced diet, with dishes to satisfy cultural needs. EVIDENCE: Two of the residents have a day care programme, which covers Mondays to Fridays. One resident attends the SFI day centre each day and the other resident attends a day centre in Harrow for part of the week and the SFI day centre on other days. Going to day centres enables residents to meet other people and to socialise. The third resident said that they work part time and that they have recently increased the days that they work from 2 to 3. They attend the SFI day centre on the other days, if they wish, and enjoy helping out. The manager said that assistance is given to residents with any benefits/finance problems. During the inspection the member of staff said that a continental breakfast was now served rather than a “fry up”. Fresh fruit was prepared and offered to residents. The menu for week commencing 3rd November was examined. The
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 13 menu was varied and balanced. Individual food records were seen and were up to date. There was evidence of alternative meals being served when a resident did not like the main dish. The menu included meals to meet the cultural needs of residents. A resident confirmed that West Indian food was served in the home. One of the residents was taking a packed lunch with them to the day centre and it included a sandwich, yoghurt and a piece of fresh fruit. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 Residents receive assistance with or prompting with personal care in a manner, which respects their dignity. Residents are supported by staff to take their medication, at the times directed and in the doses prescribed by their GP, in order to promote their general health. EVIDENCE: The manager said that the self-esteem of residents is maintained by appropriate and smart clothing. It was noted that residents were clean and tidy and well dressed. Advice about clothing appropriate for the weather was given tactfully. Times for getting up and going to bed are flexible at the weekends and some of the residents like to have a lie in. During the week residents get up in time for day centres or for work and had breakfast and got ready without appearing to be rushed. As there are only 3 residents living in the home, the staff team does not operate a system of key workers and all staff are expected to be familiar with the needs of each resident. The member of staff on duty was aware of the resident’s individual likes and dislikes. The manager said that a system of swipe cards was to be installed in the home for staff entering and leaving the premises and a monitor has been installed in the entrance hall for receiving the signal. The storage of medication was inspected and was safe and secure. The records of the administration of medication were up to date and complete. The
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 15 home uses a system of dosette boxes, which are filled by the pharmacist. These were inspected and the medication had been appropriately administered prior to the inspection. The member of staff on duty confirmed that she had undertaken medication training 2 months ago and was able to describe some of the topics covered during the course. During the inspection residents were prompted to take their 8 am medication and the member of staff did so in a tactful manner, which preserved the dignity of the resident. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the standards were inspected during this inspection. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the standards were inspected during the inspection. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. However the total weekly hours worked by individual members of staff need to be recorded so that the home can demonstrate that the number of hours worked does not compromise the wellbeing of residents. To monitor the quality and continuity of care throughout the week the manager should work occasional evening and weekend shifts. The recruitment process is not sufficient to protect the welfare of the residents. EVIDENCE: During the previous inspection a requirement was made that 50 of carers achieve an NVQ level 2 qualification. The timescale for implementation had not expired and so this was not inspected. Staff work shifts in more than one of the care homes belonging to the company and the member of staff on duty in College Road went to work at Pettsgrove Avenue after her shift in College Road had ended. On examining the rotas of the 3 care homes it was noted that there was no record of the total hours worked per week by members of staff. The hours of the manager of College Road were recorded on the rota. The hours recorded were 9 am to 5 pm, Mondays to Fridays. Staffing levels were sufficient to meet the needs of current residents.
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 19 Staff work shifts in more than one of the care homes belonging to the company and so all the staff files at head office were inspected. It was noted that 5 staff files did not contain an enhanced CRB disclosure, 3 staff files contained a CRB disclosure that had been obtained during employment prior to working at S.F.I., 3 files did not contain evidence of 2 satisfactory references, 8 files did not contain evidence of proof of ID, 5 files did not contain evidence of the member of staff’s right to work in the UK, 2 files contained information about student status without information about the number of hours that they are allowed to work, 1 file contained information about visitor status without information about whether they were allowed to work, 1 file contained a work permit that had expired and one file contained information about a work permit being refused. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 41 Residents and staff need the guidance, advice and support of the manager and the registered manager should contact the CSCI for advice when considering taking on additional duties. EVIDENCE: On the day of the inspection the manager of the home, who is also the proprietor of each of the SFI care homes, was covering the managerial duties of the other 2 homes as the registered managers were on leave. The manager said that while one manager’s absence was planned the other manager’s absence was due to an emergency. It is recommended that the manager contacts the CSCI for advice when an emergency affects the running of other SFI homes. The need for a recognised system of deputies in the homes was discussed with the proprietor during the inspection. The member of staff confirmed that the policies and procedures manual was kept in the office and that she had access to this at all times. She said that she read through these when she was on duty in the evenings. She confirmed
4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 21 that these were subject to review and that when amendments were made the staff team was notified by memo and was able to name certain key policies and procedures in the home. She linked the medication policy to a recent medication training course. However a description of what key policies and procedures contained was very brief. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 22 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 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 1 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
4 College Road Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X 3 X X 2 X X DS0000017436.V265799.R01.S.doc Version 5.0 Page 23 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 YA7 Regulation 12.1 Requirement That care is taken to ensure that money belonging to a resident is kept in their named locked tin. That savings account books are available for inspection. That the home collects the resident’s contributions to the fees that may be owing. That there is a record of the review of risk assessments included in the residents case file. That 50 of staff achieve an NVQ level 2 or 3 qualification. That the total number of hours worked per week by a member of staff is available in the home. (Previous timescale of 01 October 2005 not met). Enhanced CRB disclosure application forms must be completed and submitted for the 5 members of staff who did not have a CRB disclosure and for the 3 members of staff who have provided CRB disclosures obtained prior to their employment with S.F.I. That when new staff are
DS0000017436.V265799.R01.S.doc Timescale for action 08/11/05 2 3 4 YA7 YA7 YA9 17.2S4.9 12.1 13.4 08/11/05 01/12/05 01/12/05 5 6 YA32 YA33 18.1 18.1 31/12/05 08/11/05 7 YA34 19.1 20/11/05 8 YA34 19.4 01/12/05
Page 24 4 College Road Version 5.0 9 10 11 YA34 YA34 YA34 19.1 19.1 19.1 employed the home obtains a satisfactory enhanced CRB disclosure, which includes a POVA check prior to taking up duties in the home. (Previous timescale of 01 October 2005 not met). That all files for members of staff 06/12/05 employed since 1st April 2002 contain 2 satisfactory references. That all staff files contain proof 06/12/05 of ID. That the files of members of staff 06/12/05 who do not hold a UK or EU passport have evidence of their right to work in the UK and that the right to work is valid and has not expired. That the files of members of staff 06/12/05 who have student or visitor status contain information confirming right to work and any restrictions on this e.g. number of hours per week. That staff are familiar with the 01/10/06 content and detail of key policies and procedures in the home. 12 YA34 19.1 13 YA41 18.1 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 Refer to Standard YA7 YA7 YA33 YA38 Good Practice Recommendations That receipts are filed away after the end of the current calendar month. That the home’s procedure for handling residents’ finances is amended to reflect changes affecting payment of benefits. That the manager works occasional evening and weekend shifts and that these are recorded on the rota. That the manager seeks advice from the CSCI when an emergency affects the running of other SFI homes.
DS0000017436.V265799.R01.S.doc Version 5.0 Page 25 4 College Road 5 5 YA38 YA41 That the company introduces a recognised system of deputies in each of the care homes. That key policies and procedures in the home are discussed as an agenda item at staff meetings. 4 College Road DS0000017436.V265799.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Harrow Area office Fourth 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
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