Inspection on 23/02/06 for Dimensions 47-48 Chichester Court

This inspection was carried out on 23rd February 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dimensions 47-48 Chichester Court 09/11/07

Dimensions 47-48 Chichester Court 28/10/06

Dimensions 47-48 Chichester Court 14/09/05

Dimensions 47-48 Chichester Court 01/02/05

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 ADULTS 18-65 47-48 Chichester Court 47-48 Chichester Court Stanmore Middlesex HA7 1DX Lead Inspector Monica Saunders Unannounced Inspection 23rd February 2006 10:00 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 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 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 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. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 47-48 Chichester Court Address 47-48 Chichester Court Stanmore Middlesex HA7 1DX 020 8905 0442/031 020 8343 8876 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) www.pentahact.org.uk PentaHact Miss Eugenia Delgado Palacios Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2005 Brief Description of the Service: 47 and 48 Chichester Court are two homes within a purpose-built complex previously managed by Hillstream Care but now by Pentahact following a merger during the late summer of 2004. The homes are managed by one person, but otherwise function individually. The homes provide long-term care and accommodation for up to 8 adults with learning disabilities. The building is maintained by the Metropolitan Housing Association. All service users have their own bedroom. The bedrooms are spread across two floors. Each house has its own lounge and dining area as well as bathrooms on each floor. There is a garden to the rear of each house. The homes are fully wheelchair accessible downstairs. Access to the first floor is by stairs only. The homes are quite close to shops, leisure facilities and local transport. A minibus is shared with the other houses in the same complex. Unrestricted parking is available on the road leading to the house. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during the morning. The Registered Manager was not present at the beginning of the inspection, due to prior commitments to training. The deputy manager assisted the inspector during the inspection process. The Registered Manager joined the inspection mid-morning as her training had been cancelled. No service users took part in the inspection process. A variety of records were looked at, including care plans and minutes of meetings. A partial tour of the premises was made. What the service does well: What has improved since the last inspection? What they could do better: The manager/staff must ensure that all signatures must be signed in the correct column of the pharmacist’s record sheets The Registered Person must ensure that the small cracks in the lounge are remedied. Staff rota should be updated to clearly show the staff identified to cover leave absences. The Manager must ensure that the agency forwards copies of two references and CRB checks prior to agency staff taking up position. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 6 The manager must review the staffing levels on the morning shifts is adequate to meet the service users needs 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. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not assessed EVIDENCE: 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Service users are consulted about the care they receive. Assessment procedures are well documented. EVIDENCE: The staff use a person-centered approach to enable service users to take responsibility for their own actions. This approach is reflected in the service users’ individual care plans, which service users contribute to. Case files examined showed individual detailed risk assessments and communication support plans available on the files. Each service user has a pictorial contract on file, which have been signed by them and a member of staff. Examination of sample files indicate that the home is in the process of starting health care plans. The files contain monthly summaries of service users daily diaries giving updates relating to social networks and relationships –including communications and interactions, activities, daily living skills, incidents and accidents. The files also include other matters such as personal development action plan recordings, which are extracted from the service users daily recordings from appointment sheets. Service users attend regular service users meetings. There are set agenda’s and guidelines for the meetings, which are printed off and left on the notice board for service users to insert any issues they may wish to discuss at the 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 10 meeting as an itemed agenda. The minutes are made more user-friendly by the use of pictures and read out to service users at each meeting. They each receive a copy of the minutes. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 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 the following standard(s): 13, 16 Service users are motivated to achieve a more independent life style and to develop appropriate leisure activities. EVIDENCE: The inspector noted that there were documented key worker sessions, which detailed discussions with service users around activities they are involved in or might like to take part in, in the local community. Discussions with staff members confirmed this. The ethos of the home very much supports the service user’s independence. . Information on how individual lifestyles are supported by staff is reflected in the service users care records. Talking with staff and looking at policies and procedures supported this. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Arrangements are in place to meet the health and personal care needs of the service users. Service users receive the personal guidance and support they require. Good medication policies are in place. EVIDENCE: The home provides personal care to those service users who require support. Staff interaction with service users was observed during the inspection. Staff were seen to offer flexible and sensitive support. Service user and key worker agreements determine the level of personal support provided, which is reflected in the individual plan of care. Examination of files indicated that the home deals professionally, respectfully, and sensitively with service users personal information. The health care needs of service users were seen in their individual files. Policies and procedures for reporting accidents and incidents are being adhered to. Examination of sample files indicate that the home is in the process of starting health care plans. The files contain monthly summaries of service users daily dairies giving updates relating to health and general well being. E.g. attendance of GP or other medical appointments, incidents and accidents. Service users and staff both sign the agreed health plan. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 13 Examination of medical files, indicate that the home operates from robust medication policies and procedures. Medication is kept in a locked cabinet situated in the laundry room. Records indicate old medication is disposed of appropriately and recorded and that the chemist’s signature is obtained on their receipt of the medication. The records note that staff have signed in the chemist’s section on four occasions. The manager/staff must ensure that all signatures must be signed in the correct column. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 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 the following standard(s): 22 Service users complaints are acted upon by the home EVIDENCE: There had been no complaints made to or about the home since the last inspection. The complaints book was made available for inspection and was seen to be up to date with clear information on action taken to address previous complaints. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 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 the following standard(s): 24, 26, 30 The environment is warm friendly and inviting and offers a homely place to live for service users. The home should address the minor works required to keep the home in good condition. EVIDENCE: The communal areas of the home are well decorated. These include the bedrooms, kitchen and the dining areas; generally these spaces are used or occupied by service users. A ceiling to wall crack is apparent on the wall space near the radiator leading to the sliding patio doors and above the kitchen door leading from the lounge. The manager informed the inspector that the surveyor has been contacted regarding the internal cracks to the building. The manager must ensure that a risk assessment is carried out to manage the health and safety of the service users whilst the work is being carried out. The bathrooms and toilet facilities are of high standards and adequate in ratio to the number of service users. A walk in shower to promote independence is available for service users. The home has procedures in place to prevent the spread of infection. The home was clean and hygienic and free from odours. The manager said the carpet in the hallway together with two bedrooms upstairs in house No 48 will be removed, and replaced with hardwood effect flooring in April 06. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 16 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, 36 Staff have the skills knowledge and appropriate attitude to meet the needs of the service users and aims and objectives of the home. Staffing levels were noted to be inadequate during a period of change over in the mornings. Staff would benefit from timely appraisals. EVIDENCE: There is a multi skilled staff team that has a full time registered manager and a part-time locum deputy manager. In house No.47 there are 4 x permanent, 1 x waking night, and 4.5 x relief workers, 1 x staff vacancy. In house No 48 there are 3 x full time posts, 1 x 20 hr part time, 1 x waking night staff. The manager hopes to recruit permanent staff to the posts in the near future. The deputy manager said the home utilizes relief staff to fill support workers absences, and further commented that the staffing situation does not impact on the care for the service users. The rota’s seen during the inspection indicated that there was inadequate staffing between waking night staff going off shift and day staff commencing shift. Leaving one staff member to support service users with their personal care and breakfast between 7.30 and 9.00am. The manager must review this practise to ensure that there are adequate staffing levels to meet the service users ‘needs. Staff rota had not been updated to the staff cover for the annual leave of waking night staff. The manager should ensure this is carried out. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 17 There is a robust equal opportunities recruitment and selection process. The manager’s personal file contained relevant documentation for this process. Staff files were sampled and it was evident that staff are supported with regular supervision. Supervision records recorded that the last supervision dates were in January 2006. Appraisals were noted to be overdue, one file indicating a last appraisal from March 04. The manager must ensure that appraisals are carried out regularly each year. Regular attendance of training was noted on files. Full recruitment checks of the agency staff were not present on file. The manager must ensure that copies of two references and CRB checks are received prior to agency staff starting employment. Records examined denote that regular team manager’s meetings take place within the organisation. In addition there are regular staff team meetings, at which agenda items include: aggressive behaviour, strategies, guidelines in managing behaviour, staff changes, mission statement (staff helped the manager to develop this) 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 18 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): 37,39 The registered manager is qualified and experienced to run the home. The home is currently reviewing the quality of care for service users. The health safety and welfare of the service users are promoted and protected. EVIDENCE: The Registered Manager is suitably qualified to meet the standards of registration with CSCI. The manager has devised a questionnaire, and proposes to use video recordings with prior permission from service users/family members to make videos of service users. A letter has been sent to family members to make this request. The survey will be a tool for the home to measure their success in achieving their aims and objectives. However, it is evident that service users constantly give feedback about how they feel about the service they receive through key working sessions and house meetings. Records show that monthly Proprietor reports are carried out, which include quality checks on: Finance audits pharmacist medication audits, Health & safety audit, operations audit and fire safety audits. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 19 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 Standard No Score 1 x 2 x 3 x 4 x 5 x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 x 3 3 x 3 x ENVIRONMENT Standard No Score 24 2 25 x 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x x x 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 17 Requirement The manager/staff must ensure that all signatures must be signed in the correct column of the pharmacists record sheets The manager must ensure that a risk assessment is carried out to manage the health and safety of the service users whilst the work is being carried out. The manager must ensure that copies of two references and CRB checks are received prior to agency staff starting employment. The manager must carry out regular yearly appraisals of each staff member. The manager must review the use of only one staff member on shift in the mornings in each house to ensue that service user’s needs are being met. Timescale for action 30/04/06 2. YA24 23 15/06/06 3. YA33 18 15/04/06 4. 5. YA32 YA33 18 18 30/06/06 15/04/06 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA33 Good Practice Recommendations Staff rota should be updated to show staff cover for leave absences. 47-48 Chichester Court DS0000062639.V283668.R01.S.doc Version 5.1 Page 22 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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