Inspection on 04/04/06 for Dimensions 54 Beechcroft Gardens

This inspection was carried out on 4th April 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dimensions 54 Beechcroft Gardens 20/11/07

Dimensions 54 Beechcroft Gardens 16/09/05

Dimensions 54 Beechcroft Gardens 04/04/05

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 Pentahact 54 Beechcroft Gardens 54 Beechcroft Gardens Wembley Middlesex HA9 8EP Lead Inspector Dia Balraj Unannounced Inspection 4th April 2006 09:00 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.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 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.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. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pentahact 54 Beechcroft Gardens Address 54 Beechcroft Gardens Wembley Middlesex HA9 8EP 020 8904 8258 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 Olufunmilayo Sarah Talabi Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th September 2005 Brief Description of the Service: 54 Beechcroft Gardens is a registered detached 3-bedroom bungalow located near central Wembley. It is also near to a variety of health care, social and leisure services and facilities. The home is registered to provide 24-houraccommodatiopn and care support to 3 adults who have mild to moderate learning disability. There is a registered manager in post. The home is suitable for residents who are users of wheelchair and/ or experience other mobility difficulties. The local health authority owns the property and Pentahatch provides the care support. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector commenced the visit in the early morning and was able to speak to all three residents. One resident left for the day centre but the two other residents were present for the entire duration of the inspection. The inspector had ample opportunities to observe the interaction between staff and residents. The inspector was able to gauge the quality of care by interviewing residents and staff and observing the interaction between staff and residents. The inspector spent time with the manager viewing records, policies and discussing various aspects of care relating to the home. The inspector would like to thank the residents, the manager and staff for making her welcome and facilitating the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments are required on all activities in which residents participate to ensure the safety of residents at all times. The home must ensure that the vacant post of support worker is filled. Please contact the provider for advice of actions taken in response to this Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.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 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.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): 1, 2, 3 & 5 An assessment of residents’ needs is completed prior to admission and residents are made aware of how their needs will be met. EVIDENCE: The inspector spoke with all three residents. Residents stated that they were given adequate verbal and written information about the layout, staffing, the key worker system, care support programmes and the range of services and facilities available. Residents had an understanding of the assessment process and how it helped to identify their care and social needs. Two of the residents had a good understanding of how staff help them to achieve the objectives identified in the care plans. The residents also reported they understood their responsibilities as residents as outlined in the contracts. These have been written in a style that meets the communication needs and abilities of each resident. The care plans and reviews are designed to enable residents to participate in the process. The inspector noted that there were comprehensive care needs assessments and reviews carried out for each resident. These also have input from a range of professionals and other significant persons related to the residents. The care planning is person centred and the evidence examined by the inspector, showed the progress being made in achieving the objectives identified in the care plans. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 9 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 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): 6, 7, 8 and 9. The individual care plans reflect the assessed and changing needs of residents. Residents participate in various aspects of life in the home and are encouraged to be as independent as possible. EVIDENCE: The inspector spoke with residents and examined the individual care plans. The levels and types of support are recorded for each resident. There was evidence of life stories and photographs of significant events in the personal file for each resident. The inspector observed each resident actively involved in tasks around the home, including assistance in the kitchen, dining area and individual bedrooms. Staff were observed discussing meal options. A resident stated that she was encouraged to be involved in the selection of staff. One resident has been actively supported and encouraged to develop the ability to access public transportation independently. This has helped to enhance the resident’s confidence and awareness of her ability to utilise community services outside the home. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 11 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 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): 11, 12, 13, 14, 15, 16 & 17. Residents have opportunities for personal development and are supported to engage in activities to meet their individual needs. Residents are offered a healthy diet. EVIDENCE: The inspector observed the opportunities given to residents to develop their independent living skills, social and communication skills. The evidence examined and feedback from staff and residents confirmed that residents are supported to learn new skills and tasks centred work at day centres. Residents were assisted to do tasks in the kitchen, to ensure that their bedrooms are kept clean and orderly. Each resident has an individual programme of activities to meet their individual choices. These included bowling, library, shopping, cookery sessions, tea dances, cinema, Harrow concert and bingo. In addition residents attend activities at Neasden Resource centre, barbecue parties, and social evenings at a local pub, meals out at restaurants plus holiday trips abroad. Each resident is supported by staff to develop a Life Book, which includes significant events about their lives. The books contain a range of personal events, work history, relationship and meetings with friends, families, learning Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 13 experiences, travels and special events such as birthdays. Residents have developed appropriate relationships and spoke of the support given by their advocate. The residents play active role in meal planning and staff provided recorded evidence of meals planned and consumed by residents. On the day of inspection staff was observed planning the evening meal with residents and finding out if they wanted any changes to the menu. The planning also included special diets. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 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, 19 & 20 Residents receive personal support in the way they prefer. Residents’ physical needs are met. The administration of medication was in order. EVIDENCE: The care plans were individualised with evidence of input from each resident. There were good examples of each resident’s health care needs and assessment with recordings of medical and other health care appointments and inputs. On the day of inspection a resident was attending a medical appointment and spoke with the Inspector regarding the nature of the appointment. The evidence obtained from speaking to residents and staff indicated that staff enabled residents to participate fully in their health care with examples of staff explaining to a resident the need for a medical appointment. The manager stated that she had contacted the bereavement counselling service to offer support to a resident but was still awaiting a response. This must be pursued to meet the needs of a particular resident. On the day of inspection the medication records were in order. A recent visit from the community Pharmacist confirmed that the administration of medication was in order. The manager stated that 5 members of staff had had medication training. However medication is also administered by staff, who Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 15 have not had accredited medication training. It is required that all staff who administer medication have followed accredited medication training. The home has benefited from periodic visits and inspection by the district nursing service. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 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): 22 &23 Residents are encouraged to express their views. Procedures are in place to protect residents from and to deal with incidents of abuse. EVIDENCE: Residents were aware of the complaints procedure, a copy of which was displayed. The inspector was able to observe clear communication between staff and residents. Residents were observed communicating their concerns, views and ideas to staff. The residents also have regular house meetings and there was recorded evidence of residents communicating their wishes, concerns, and of making plans for the redecoration or purchase of furniture for the home. The home’s complaints and daily records’ books are also used to record resident’s concerns and views. Each staff is expected to read this recorded information and where necessary, take appropriate action. The staff have had POVA training and staff interviewed had knowledge of the Public Interest Disclosure Act and the Whistle blowing policy. There was evidence of strategies for dealing with challenging behaviour. The home is currently investigating an allegation made by a resident. The inspector was satisfied that the correct procedure was being followed. The manager stated that residents manage their own money. This was confirmed by residents. The inspector checked the records of money of one resident, which was in order. An advocate is available to residents who stated that they often talked to her. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 17 Regular staff supervision and the person in control monitoring visits also help to ensure the rights, wellbeing and welfare of residents are safeguarded and protected. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 18 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, 25,26,27,28,29,30 Residents live in a home that is well maintained, clean and offers facilities to foster their independence. EVIDENCE: The home was clean and hygienic. The home is also accessible to users of wheelchair. Appropriate grab rails and other mobility and safety aids are also installed throughout the home. The garden was well maintained and several areas of the home had renovation and decoration in the last few months. There are adequate bath and toilet facilities for the three residents and also for staff and visitors. Each resident’s bedroom is decorated to individual style, preferences and furnished with items that have been individually chosen. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 19 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 &35 Residents are supported by staff who understand their individual needs. EVIDENCE: During the inspection process it was observed that staff were accessible to and residents were comfortable with staff. Three of the four permanent members of staff possess an NVQ qualification. In addition Staff’s profile and discussions with staff showed that they had followed a number of training courses: fire safety, first aid, food handling, Protection of vulnerable adults, moving and handling, medication training, communication with adults with learning disability, health awareness, loss and bereavement, challenging behaviour. The inspector spoke to a resident and to her key worker and examined the individual plan of the resident. There was evidence of the resident’s satisfaction with the member of staff who she described as “very helpful”. The interaction between them was also relaxed. The care plans informed that monthly reviews are undertaken and of the involvement of specialists including physiotherapy and psychiatric inputs.. The home has a support worker vacancy. On the day of the inspection the evening and night shifts were covered by bank staff. The inspector observed that the member of staff on the evening shift interacted well with residents and had knowledge of their needs. The manager stated that she was satisfied that the member of staff was competent and had been working at the home for over a year. The night staff on duty was aware that she should contact an on call manager from Pentahact if she needed guidance.. Details of on call duty were posted in the office. It is required that night duty staffing levels are Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 20 reviewed on a regular basis to ensure that it reflects residents’ changing needs. The manager confirmed that the organisation operates a thorough recruitment procedure with the appropriate checks. This information is available at head office and was not checked on this inspection. The inspector checked the individual training profiles of staff. Staff receive regular recorded supervision and records were available. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 21 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, & 42 Residents live in a home where the management approach encourages feedback from residents and staff. Residents’ views influence the way the home operates. EVIDENCE: The manager has been in position for several years and is well known to the residents. She is currently undertaking the NVQ care management training and has undertaken a number of courses to update her skills.. The inspection findings found documented evidence to suggest that senior management undertake monitoring and development plans for the home and the services it offers to residents. Appropriate training and support is also offered to staff. Regular monthly residents’ meetings are held and these contribute to residents’ reviews. Staff have supported residents to choose furniture, carpets and settee for the living room. There was evidence that feedback from residents has influenced the smoking policy of the home. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 22 Gas and electrical wiring checks had been undertaken. The certificate of the electrical wiring check was available but did not state the expiry date. Fire checks and environmental health officer checks were in order. There was no evidence of the hot water system checks by a qualified engineer although staff checked temperatures prior to baths. Risk assessments on residents’ participation in some activities of daily living were available. However, risk assessments must be completed on all activities in which residents participate. Residents involvement for example, in the preparation of meals must be supported by risk assessments based on the specific needs of each resident to ensure residents’ safety at all times. Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 23 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 3 2 3 3 3 4 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 24 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 18 Requirement It is required that all staff who administer medication have followed accredited medication training. . It is required that night duty staffing levels are reviewed on a regular basis to ensure that it reflects residents’ changing needs. The vacant post of support worker must be filled to ensure that residents’ needs are met at all times. The registered person must obtain confirmation of the expiry date of the electrical wiring check. The registered person must ensure that the hot water system is checked by a qualified engineer on a regular basis All activities in which residents participate must be supported by risk assessments based on the specific needs of each resident to ensure residents’ safety at all times. The registered person must ensure that the resident concerned is offered the support DS0000062638.V287805.R01.S.doc Timescale for action 31/05/06 2 YA33 18 30/04/06 3 YA33 18 15/05/06 4 YA42Y 13 31/05/06 5 YA42 13 31/05/06 6 YA42 13 30/05/06 7 YA19 13 30/05/06 Pentahact 54 Beechcroft Gardens Version 5.1 Page 25 of a counsellor to meet her individual needs. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 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 © 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 Pentahact 54 Beechcroft Gardens DS0000062638.V287805.R01.S.doc Version 5.1 Page 27 - 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. 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