Inspection on 18/11/05 for Adepta John Paul House 7-9 Pound Lane

This inspection was carried out on 18th November 2005.

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

Other inspections for this house

Adepta John Paul House 7-9 Pound... 30/09/09

Adepta John Paul House 7-9 Pound... 02/10/08

Adepta John Paul House 7-9 Pound... 02/10/07

Adepta John Paul House 7-9 Pound... 25/05/06

Adepta John Paul House 7-9 Pound... 13/06/05

Adepta John Paul House 7-9 Pound... 09/12/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 John Paul House, 7-9 Pound Lane John Paul House 7-9 Pound Lane Willesden London NW10 2HS Lead Inspector Virginia Allen Unannounced Inspection 18th November 2005 08:00 John Paul House, 7-9 Pound Lane DS0000062635.V266731.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 John Paul House, 7-9 Pound Lane DS0000062635.V266731.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. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service John Paul House, 7-9 Pound Lane Address John Paul House 7-9 Pound Lane Willesden London NW10 2HS 020 8451 6843 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) PentaHact Lorenzo Domech Care Home 8 Category(ies) of Learning disability (8) registration, with number of places John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: John Paul House is one of a number of care homes formally managed by Hillstream Care Limited. The organisation merged with Pentahact in September 2004. The home is registered to accommodate 8 adults with learning disabilities. The property is situated on Pound Lane, Willesden where there are good links with public transport. There are a number of shops close by. The property is detached and has a large driveway for off street parking. There is a large garden at the rear. The property consists of two floors. On the ground floor there are two bedrooms, a shared toilet and bathroom, an office, lounge room, laundry and a kitchen dinette. On the first floor are 6 further bedrooms for residents, bathroom with toilet, separate toilet, storeroom and a staff bedroom. Residents attend local day services and are supported to use community facilities such as leisure centres, parks etc. The home has its own transport. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out in the morning. There were three staff on duty assisting seven service users. However, five of the service users left after breakfast to attend day care. The residents have a range of learning disabilities and some have challenging behaviours. The majority have little or no verbal communication skills. The inspector viewed documentation for the service users and the home. She talked with the manager, the staff and the service users. She spoke at length with one of the service users who talked about his time at the home and how he was looked after. The inspector toured the building. What the service does well: What has improved since the last inspection? What they could do better: The communal space shared by 7 service users and staff is cramped. In a home where some service users have challenging behaviours, service users would benefit from having a choice of seating areas. The dining area cannot accommodate all of the service users at the same time. The windows are not double-glazed and on a main road this means that noise can interfere with sleep patterns and contribute to challenging behaviours. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 6 All documentation relating to the house including staff files must be kept at the house for inspection. All information relating to the service user should be stored in a lockable cupboard in the office. This is to preserve the confidentiality of the service user. 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. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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 John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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): 3,4 Service users know that the home that they will choose will meet their needs and aspirations. They are given to opportunity to test drive the home. EVIDENCE: Prior to admission, a full assessment is made of all of the service users needs. The service user is asked to contribute to this assessment by talking about their likes and dislikes and goals for the future. Records demonstrated a comprehensive initial assessment, which assisted the home in planning the care of the service user. The inspector discussed the service user admission procedures with the manager. Prior to admission the service user and their family receive all relevant information relating to the home and the care provided. The service user and the family are given the opportunity to visit the home and the service user can spend time with the others getting to know them. The service user is also encouraged to stay overnight and to experience the home environment before making their decision about accepting placement. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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): 7,10 Service users make decisions about their lives with assistance as needed. They know that information about them is handled appropriately and that their confidences are kept. EVIDENCE: The focus of the home is person centred. The wishes and aspirations of the service users govern the practice. The manager of the home explained to the inspector how the service users makes their own decisions about a range of issues from what to wear each day, what activities they are involved in to what they eat. This is supported by the home and it’s staff. Service users are encouraged to look after their own finances. Three service users manage their own finances, three are managed by the home and one has their finances managed by their family. All of their likes and dislikes are documented in their care plans. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 10 Current service users are encouraged to pursue their own interests and take appropriate risks. Risk assessments are in place. All records in the home should be stored in a lockable cupboard in the office to preserve the privacy of the service user. The home has a policy of confidentiality which is written in service user-friendly format and which has been given to all of the service users. This is good practice. The manager explained to the inspector that the service user has the right to privacy and information is only shared with others on the agreement of the service user. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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): 11,14,15,16 Service users have opportunities for personal development and are engaged in appropriate leisure activities. They have appropriate personal and family relationships. Their rights are respected and responsibilities recognised. EVIDENCE: The current service users all attend day care four days a week. During the inspection the inspector observed one service user making the choice not to attend day care. Staff supported this decision. One day a week the service users choose activities that are supervised by the home staff. Activities are chosen from a range of activities that are presented in service user-friendly format and displayed in the entry hall. The home has a car and service users are able to go shopping or to parks. However, the manager is pursuing the option of a 7-seated Transporter to allow all service users the opportunity of outings at the same time. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 12 Service users have the opportunity to go on holidays of their choice. The service user who spoke with the inspector explained that he had been to the Canary Islands, Devon and Butlins. He was happy with his holiday choices and was still deciding where to go for his next holiday. The staff acknowledge the service users right to independence and privacy within the home. The manager seen to knock on the bedroom doors before entering and the inspector noted that the service users were spoken to with dignity and respect. All bedrooms have an individual key to allow the service user the opportunity to lock their doors. Where possible service users are encouraged to help in the kitchen, set the table and to help with hoovering. This allows them to learn domestic skills. However, the service users do not need to participate in domestic tasks, other than caring for their own rooms if they do not wish to. Meals are offered three times a day with snacks in between. This is at the discretion of the service users. Family are encouraged to maintain contact with the service users. Some of the service users go home on weekends and occasionally family visit the home. The home utilises an independent advocate for those who do not have family involvement. The service users also visit the residents at other learning disability homes. This is to encourage the development of social skills. Service users are weighed regularly. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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 the following standard(s): 21 The ageing, illness and death of a service user are handled with respect and as the individual would wish. EVIDENCE: The home is currently recording the ageing, illness and death wishes of the service user in their care plans. This is still to be completed. The information is being recorded in a service user-friendly format so that the service user is confident that the information reflects their own choices. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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): 23 Service users are protected from abuse, neglect and self-harm EVIDENCE: The home has a formal Protection of Vulnerable Adult policy. However, this needs to be updated to include the Brent Protection of Vulnerable Adult guidance and the address of the Commission for Social Care Inspection Harrow office and Brent Social Services Protection of Vulnerable Adults team. The Complaints procedure is in service user-friendly format and has been distributed to the service users. The policy is on display on the entry hall notice board and accessible to family and friends. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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): 25,26,28,30 Service users bedrooms suit their needs and lifestyles and promote their independence. Shared spaces need to be expanded. The home is clean and hygienic. EVIDENCE: Several of the service users showed the inspector their bedrooms. They were very pleased with their rooms. The décor was matching and there was plenty of cupboarding and storage places. The rooms were light and airy. Some of the rooms are carpeted while others have lino on the floor. Service users should be given the option of having carpet on their bedroom floors. Service users have the option of staying in their bedrooms when they wish. The inspector noted that all of the bedroom doors had a lock so that service users have the opportunity to maintain their privacy and independence. During the inspection one of the service users was seen to lock his bedroom door while he was in his room. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 16 The communal areas are well decorated but need to be expanded. Service users need to be provided with alternative seating areas to accommodate the large number of service users and staff or for when a service user has challenging behaviours. The communal areas have comfortable seating and are centrally heated. There is a communal television although there is also provision for the service user to have their own televisions in their own rooms. The home is decorated with domestic furniture and lighting that is of good quality. It was also noted during the inspection that double-glazing did not moderate the traffic noise from the main road. The inspector spoke with the manager who agreed that some of the service users did have difficulty sleeping and that noise could be a factor. During the inspection the home was seen to be clean and hygienic. Staff are rostered to attend to domestic duties. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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 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): 31,32,33,34,36 Service users benefit from clarity of staff roles and responsibilities and are supported by competent qualified staff that is an effective team. They are protected by the homes recruitment policy and practices. Service users benefit from well-supported and supervised staff. EVIDENCE: The manager informed the inspector that when staff are employed they are provided with a job description that outlines their role and responsibilities. The current manager has resolved difficult staffing issues and is confident that he has a team of support workers who are client centred and supportive. The inspector viewed the training programme which is robust and showed that training was up to date. The home has 14 staff. Five have completed NVQ training, three are currently involved in NVQ training and two staff have recognised equivalent training. This achieves the regulatory requirement of at least 50 of staff being NVQ trained. The manager of the home is scientifically trained but has been working in care for the last 10 years. He has experience as a support worker, residential social John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 18 worker and managing a home for unaccompanied minors. He has completed NVQ training and is to register for the Registered Managers course. He has been managing the home for the last three years. The manager explained to the inspector that the home was currently advertising for more staff. The process was to short list applicants; send out a job description, interview those short-listed and to employ appropriate staff. The home has a policy of equal opportunity. The selection panel has a service user representative. Applicants must pass a CRB and POVA check before being employed. They must also have 2 satisfactory current references and show that they are eligible to work in the UK. All staff files must be stored at the home so that they are available for inspection at any time. Staff receive formal supervision every two months with the manager or the deputy manager. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 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 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): 37,38,39,40 Service users benefit from a well run home as well as the ethos, leadership and management of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Their rights and interests are safeguarded by the home’s policies and procedures. EVIDENCE: During the inspection service users were getting ready to attend day care and having their breakfast. They appeared to be happy and content. The manager informed the inspector that the ethos of the home was person centred and the promotion of independence. This meant that the home did not impose their opinions on the service user but supported them to make their own choices. They aimed to empower the service user to encourage their happiness. The manager explained that the staff showed their sensitivity to the service user by listening to their needs and acting upon them. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 20 The service user who was interviewed at length by the inspector supported this claim. He informed the inspector that he felt that his aspirations were listened to and acted on. Service user likes and dislikes are documented. The documented policies and procedures for the home reflect the focus of the home. The home has a quality assurance procedure and a copy was given to the inspector for filing at the CSCI office. John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 21 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 3 3 X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 3 X 2 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 John Paul House, 7-9 Pound Lane Score X X X 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X X X DS0000062635.V266731.R01.S.doc Version 5.0 Page 22 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 YA23 Regulation 13 Requirement The Protection of Vulnerable Adults Policy must be updated to include the contact details of the Brent POVA team and local CSCI office. (Previous timescale not met 31/1/05 and 31/7/05) The registered provider must ensure that the Occupational Therapist’s assessment recommendation to provide a walk in shower room on the ground floor to meet the changing physical needs of a service user, is carried out. (Previous timescale not met 1/3/05) Please submit to CSCI with action plan from this report, details of progress towards this end. The manager must ensure that information on staff as per Schedule 4.6 is kept in the home and made available for inspection. The manager must ensure that CRB information is kept in the home. (Request made in previous report 13/6/05) John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 23 Timescale for action 15/12/05 2 YA29YA27 23 (2) (n) 15/02/05 3 YA34 Sched 4.6 17 (1)(3) 15/12/05 4 YA10 12 (4) (a) 17 (1) (b) 5 YA42 23 (4)(a) 6 YA28 23 (2) (e) (f) (g) 7 YA28 23 (2) (a) Records pertaining to service users should be kept in a locked cupboard at all times. This is to preserve the confidentiality of information. The registered person should make sure that all fire doors are kept shut unless it is installed with mechanism for shutting with alarm. The registered person should reconsider the adequacy of the communal space provided for service users. This includes sitting areas and dining areas. The registered person should consider the installation of double-glazing on windows to moderate traffic noise and offer a more conducive sleeping environment for service users. 15/02/05 15/12/05 15/12/05 15/12/05 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 John Paul House, 7-9 Pound Lane DS0000062635.V266731.R01.S.doc Version 5.0 Page 24 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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