Inspection on 30/09/09 for Adepta John Paul House 7-9 Pound Lane

This inspection was carried out on 30th September 2009.

CQC 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 CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 20 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... 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... 18/11/05

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 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Adepta John Paul House 7-9 Pound Lane John Paul House 7-9 Pound Lane Willesden London NW10 2HS Lead Inspector Andreas Schwarz Key Unannounced Inspection 30th September 2009 09:30 Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Adepta 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 dorretta.mcgregor@adepta.org.uk www.pentahact.org.uk PentHact Ltd trading as Adepta 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) Dorretta McGregor Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2008 Brief Description of the Service: John Paul House is one of a number of care homes formerly managed by Hillstream Care Limited. The organisation merged with Pentahact in September 2004. Since September 2009 the organisation is trading as Dimension Ltd. The home is registered to accommodate 8 adults with learning disabilities. At the time of the inspection there was one vacancy. Information of the weekly fees can be obtained from the registered manager or registered provider on request. The property is situated on Pound Lane and 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 and on the ground floor there are two bedrooms, a shared toilet and bathroom. There is an office, laundry room, lounge and large kitchen/diner. On the first floor are 6 further bedrooms for people using the service, bathroom with toilet, another toilet, a storeroom and a bedroom for staff sleep-over’s. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The outcomes for people using the service are poor; this is a zero star service. This unannounced key inspection took place on the 30/09/2009 and 01/10/2009 and lasted 14 hours. The registered manager Ms Dorretta McGregor was on annual leave during the first day of this key inspection, but came to the home at 11:30 am. During the first day of this inspection the Operation Manager (Ms Sophia Phyllis) visited the home, following a phone call by the inspector. The home returned a completed Annual Quality Assurance Assessment (AQAA) within the given timescale. The AQAA provided us with information, which has been incorporated in this report. We have send service users and staff surveys to the home, two service users surveys have been returned to us. We assessed three care plans, three staffing folders and documents relevant to make a judgement on the quality of care provided by the home. During both days of this inspection seven people using the service were present and we spoke to two people using the service. Five people living at John Paul House have considerable communication difficulties and are not able to communicate verbally. We observed staff supporting and interacting with people using the service. We interviewed three members of staff during the second day of this key inspection. We would like to thank people using the service, staff, registered manager and operation manager supporting us during this unannounced key inspection. What the service does well: What has improved since the last inspection? The home has met three requirements and worked towards meeting one requirement of the five requirements made during the last key inspection. The home started to use a greater variety of pictures, which supports people using the service to communicate clearer with staff. We asked the home to review the people’s contribution for the running of the car; this has been resolved by no longer providing a vehicle for people using the service. The kitchen is now Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 6 open and people using the service can access the kitchen to help themselves to drinks and snacks. The registered manager contacted the housing association to try to get a ramp built, which leads in the garden and enables residents with mobility problems to access the garden independently. The housing association requires an Occupational Therapy (OT) assessment, which is still found outstanding due to the eleven months waiting list at the OT department. The home has started to change the carpet in the hallway, but work is still in process to be completed. What they could do better: The quality rating of the home changed from two stars (good) to zero star (poor). We have made twenty requirements and six good practice recommendations during this key inspection. The homes statement of purpose and service users guide does not provide up to date information to current and prospective people using the service. Support procedures such as supporting people with rectal diazepam must be updated and changed, if this support is no longer provided. The home must ensure that the risk to people when carrying out maintenance work in the property is assessed and managed safely. The home must ensure that at all times adequate and skilled staff is available to support people using the service safely. A range of varied and stimulating activities must be discussed and offered to people using the service. Records of activities must be up to date and reflect what actually has happened in John Paul House. The home must discuss and provide a seven day annual holiday to all people using the service. People using the service must have a range of opportunities to meet people, make friendships and maintain relationships. Staff and management must provide toilet facilities, which maintain people’s dignity and privacy. Actions and recommendations made by health care professionals must be followed, which helps people to improve their health and behaviour. Staff competent in the medication administration must provide their signature, so people using the service are assured that medication is administered safely. The home must ensure that maintenance work is carried out safely without putting people at risk of injury. At any time tools and equipment used by contractors must be kept safe, ensuring people using service are not at harm. The home must ensure people using the service can safely access the garden, without the risk of falling. Urine smell in communal and personal space must be resolved, ensuring a clean and healthy environment is provided to people using the service. Carpets which are worn or unsafe in service users rooms must be replaced, to reduce the risk of tripping or falling. Cleaning materials must be kept locked at all times and can only be accessed by people if it is safe to do so. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 7 The registered manager must commence her qualifications in care and management to reassure service users that the home is managed by a qualified person. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 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 Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 1 and 2 during this inspection. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. Prospective individuals are given the opportunity to spend time in the home. Prospective people using the service are issued with suitable information about the home; some updating is needed to reflect the changes the organisation has undergone. EVIDENCE: People using the service are issued with a service user’s guide and statement of purpose a copy of both documents is available in the care plan folder. The service user’s guide is also available with pictures, which is suitable for the people living at John Paul House. People using the service were not able to tell us if they have seen the documents. We discussed both documents with the registered manager and informed her that the documents must be updated to include the information of the merger with Dimensions and the changes of the Care Quality Commission’s (CQC) contact details. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 10 The home did not have any new admission since the last key inspection and has currently no vacancies. We looked at one assessment; the assessment was detailed and provided good information about the resident. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 6, 7 and 9 during this inspection. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is drawing up person centred care plans together with people using the service, there is however a need to update the plans if care approaches have changed. People using the service are encouraged to make individual choices of what they want to do. Risks are assessed generally very well; there is however a lack of pro-actively looking at risks to people using the service when maintenance and repair work is carried out. EVIDENCE: We assessed three care plans in detail during this inspection. Care plans were found to be detailed and are available in a suitable format for people using the service. Care plans have been reviewed and long as well as short term goals have been discussed. Guidance in how to monitor and achieve the goals are in Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 12 place. Assessments if people have mobility problems and/or behavioural issues are in place and are reviewed during the annual care plan review. All people using the service have an allocated key worker. We spoke to one person who informed us that he knows his new key worker and that he has met with him to discuss holiday plans to Ireland. We noted in one of the care plans viewed that the person can only go out with staff who has been trained in the administration of rectal Diazepam. We discussed this with the registered manager who informed us that rectal Diazepam is not administered by care workers and the information is out of date. We looked at the Epilepsy guidance, which confirms this. The home has a current care plan folder and an archive folder, we noted that on two occasions the archive folder was almost impossible to open due to the amount of information it contained. Some documents have been in the folder since people moved into John Paul House. We noted that two of the people we assessed during this key inspection have an advocate and one person has applied with Brent Advocacy to have an advocate allocated. Unfortunately due to a long waiting list the person is still waiting to meet his allocated independent advocate. The home is using pictures for people to make choices about the food they want to eat. We observed staff asking service users what they want to have for lunch and on the second day we overheard discussions with people using the service about were to go during the morning. People using the service can access the kitchen at any time, which was a problem during the last key inspection. One person told us that he chooses to go on holiday to Ireland, which he discussed with his key worker. People with communication difficulties are referred to Speech and Language Therapy for assessment and appropriate communication aids are used and investigated. Staff support people using the service to receive the correct benefit and the manager told us that she is currently in the process of asking the Department for Work and Pensions (DWP) to reassess a person for higher benefits. We viewed financial records of three people. People using the service have their own bank account. Records viewed are of good standard and expenditure and income is recorded thoroughly. Staff is checking peoples individual money pouches during each handover and close it with a seal each time. We observed staff taking out money for activities and a record is made for each transaction. People are encouraged to take risks and detailed risk assessments are in place. Risk assessments provide staff and people using the service with a plan in how to manage the risk safely. During the first day of this key inspection, contractors visited the home to replace the carpet. We noted that no risk assessment for the planned work has been put into place and the contractors left tools and equipment lying around, this could have lead to people using the service injuring themselves. It also appeared that the contractors were not aware of the peoples needs and continued working while one person was using the toilet. The toilet door was open and the person was fully exposed to the contractors. If a risk assessment would have been put into place prior to the Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 13 work commencing, the contractors would have had clear guidance and instructions of how to carry out the work safely. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: We assessed National Minimum Standards 12, 13, 14, 15, 16 and 17 during this inspection. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service access daycentres regularly, but there is a lack on leisure, in-house and community based activities. This would help people using the service to expand their interest, meet new people and experience a full filling and stimulating live. The home provides a healthy, nutritious and culturally appropriate diet, which is chosen by people using the service. EVIDENCE: Five of the people living at John Paul House access local day centres. The day centre provides them with learning opportunities and activities suitable to their needs. None of the people living at the home are in paid or unpaid employment or access colleges. The registered manager told us that this is due Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 15 to their complex needs. We spoke to one person and asked him if he would like to go to college and he told us that he is “happy going to Willesden Resource Centre” (WRC). The person also told us that he goes occasionally to Willesden Library, which he would do more often. When we asked him why he is not able to go more often he told us, that it is because there is not enough staff. Care plans assessed showed us that people using the service would like to go for walks, restaurants, café’s, the library, fishing, etc. We spoke to one person who confirmed that he likes to go to restaurants and wants to go fishing. He informed us however that he has not been fishing and can’t remember the last time he has been to a restaurant. We viewed the daily records of this person for 05/07/2009 to 28/07/2009, which recorded no activities apart from watching television and relaxing in the lounge. Following this we looked at daily records of another two people using the service for the whole of September 2009. One person went to Karaoke on 21/09/2009 and went out with staff on 25/09/2009. The second person visited the brother on 06/09/2009 and 27/09/2009, and went to church on 20/09/2009. This demonstrates that three different people using the service had five different activities over the course of one month. We discussed this with the manager who told us that people using the service go out more often, but staff doesn’t record activities as they actually happen. One staff member told us that “they could do more activities”. During our previous key inspection (02/10/2008) we found similar issues. “We discussed this with staff, which informed us that due to the current staffing situation it is very difficult to provide community based activities for residents”. The staffing levels have not been reviewed since the last key inspection and the requirement has not been met. The manager told us that the home has good relationships with their neighbours. The manager told us that people using the service have been on day trips during the summer. People using the service have not been on an annual holiday during 2009. Action plans in the three care plans assessed recorded that people using the service should be assisted by staff to choose a holiday destination and go on a holiday. Five people living at John Paul House access WRC to maintain relationships. One person told us, “I can see my friends at the day centre”. One person told us that the home is helping him to make contact with family members, which has proved to be very difficult. People who have family are encouraged to maintain contact and regular visits are encouraged. The lack of community based activities however limits the opportunities for people using the service to meet new people and built new relationships. People used to go regularly to gateway club, but evidence showed us that this has stopped. One person’s care plan stated that regular visits to other homes should be arranged. Daily records from 1st-30th September did not document any visits for this person. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 16 We observed people using the service accessing all parts of the home, access is only limited to the laundry room, which is clearly stated in a risk assessment. One person told us that he can go to his room and relax on his own if he chooses to do so; we observed this during the first day of this inspection. We observed people using the service helping staff to prepare the evening meal and one person told us that she likes helping in the kitchen. Daily records of one person confirmed that she regularly is involved in household chores. The home is using a pictorial menu, which allows people using the service to choose what they like to eat. Alternatives are offered if people don’t like the meal or want to have potatoes instead of rice. Staff informed us that the menu is done weekly and is based on people likes and dislikes. Meal options are recorded on the menu. Two of the people using the service have Type 2 Diabetes, staff is aware of this and sweeteners as well as low sugar options are provided. Staff told us that two people using the service are slightly overweight and support people reducing the weight by providing fresh fruit, fresh vegetable and low fat desserts. We recommend looking into providing activities, which helps people to reduce or maintain their weight. The home has a newly build sports centre nearby, which can be accessed by people with disabilities at no cost. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 18, 19 and 20 during this inspection. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are assisted by staff to maintain their personal hygiene and are supported around their personal care, occasionally their dignity and privacy is not ensured. The home is supporting people in accessing health care professionals, but staff does not always follow instructions given by health care professionals. People using the service are protected by a robust medication procedure, but are not always informed if staff is competent in the administration of medication. EVIDENCE: We viewed personal care guidance in peoples care plan files. Staff spoken to demonstrated understanding of how to support people around their personal care. We discussed with a member of staff and the manager the issue of a person not being dressed appropriately. We were informed that over the past Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 18 months the person has started to refuse getting dressed. This has been picked up and the home is planning to assess the person by the in-house behaviour intervention team and look at triggers and ways to change this new behaviour. People using the service appeared to know where bathrooms and toilets are located in the home. We observed one resident sitting on the toilet with the door open; staff told us that the person does not close the door when the person is using the toilet. This was observed during the time contractors replaced the carpet. The contractors were able to see the person semi naked, which is not judged as very dignifying to the person and does not ensure her privacy. People using the service are supported in attending dental and optician visits. The home accesses Brent Learning Disability Team (BLDT) for specialist health care support such as psychology, psychiatry and speech and language therapy. The home uses the in-house behaviour intervention team to support people using the service to reduce challenging behaviour. All people are registered with their own General Practitioner (GP). We viewed detailed health assessments and health action plans, which are completed by staff and provided by Brent Primary Care Trust (PCT). Visits to health care professionals are recorded and action documented. One person told us that he visited his GP to discuss issues with his legs. People’s epilepsy is monitored and an individual epilepsy management plan is in place. We viewed a letter dated 08/04/2009 from the neurology department at Central Middlesex Hospital (CMH), raising concerns that instructions given by health care professionals were not followed by the home and staff lack cooperation when working with health care professionals’. We assessed medication administration sheets (MAR) of three people. The MAR sheets had no gaps, people’s allergies are recorded and a picture of the person is in place. The home has a signatory list of staff competent in the administration of medication in place; we noted however that the list is out of date. The dispensing pharmacist is monitoring medication and recommendations made during the most recent visit have been actioned. Liquid medication bottles are signed once opened. The home has an up to date medication policy and procedure in place. The medication cupboard is lockable and a sufficient amount of medication is kept in the home. We noted that some medication has expired or is no longer in use and recommend returning these to the pharmacist for disposal. Senior support workers are responsible for the administration of medication and training is provided by Dimensions. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 22 and 23 during this inspection. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are encouraged to raise satisfaction and dissatisfaction about the support and care provided by the home. There are major downfalls in the homes safeguarding systems and people’s safety is compromised. EVIDENCE: The home sent us an Annual Quality Assurance Assessment (AQAA). The AQAA told us that the home did not receive any complaints since the last key inspection. We viewed the homes complaints records and noted that a member of staff made a complaint in regards of cancelling shifts. The complaint has been investigated by the registered manager and the outcome of the complaint and actions have been clearly documented. The home has a complaints procedure, which is also available in pictorial format. The manager told us that complaints procedure was previously displayed on the notice board in the kitchen, but had to be removed due to a service user’s request. We spoke to staff who informed us that they know how to record complaints and explained that they would talk to the registered manager. One of the people using the service commented, “I would talk to my key worker or the manager”. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 20 The home had four safeguarding referrals since the last key inspection. One was not substantiated. Three safeguarding referrals are currently open and are dealt with by the hosting borough Brent. Training records showed us that staff have attended safeguarding adults training. The home is planning Mental Capacity Training (MCA) for 06/10/2009, adult protection training for 10/09/2009 and Deprivation of Liberty Safeguards (DoLS) training. Staff confirmed that they will and have attended the training. During the first day of this key inspection, the 30/09/2009 we arrived at 09:30 am. Staff informed us that the registered manager Ms Dorretta McGregor is on annual leave and contractors will visit the home to replace the old carpet with new linoleum flooring in the hallway. The contractors arrived at 10:00 am. The contractors started to remove the old carpet and levelled the concrete floor for the linoleum flooring to be laid. This created a lot of dust, we found tools lying all over the floor and the front door was wide open to provide some air. Once the floor was prepared glue was applied to stick the linoleum to the concrete floor. We noted a strong smell of toxic fumes from the glue. People using the service were moving around while the work was carried. One member of staff supported a person in his room and was not able to support his colleagues’ supporting and observing the other five people using the service. We observed staff becoming very stressed and heard them arguing with each other. At one point a service user used the toilet, with the door open allowing the contractors to look in and see her semi naked. We were concerned about the safety of the people using the service and talked to staff, who voiced similar concerns. At this point we contacted Sophia Phyllis (Operation Manager) and informed her of our concern and advised her that the staff team is not able to cope with this situation. Ms Phyllis explained that she will come as soon as possible to support staff resolving the situation. While we were waiting for the Operation Manager we assisted staff obviously struggling with supporting people using the service. At around 11:30 am the registered manager Ms McGregor and the operation manager Ms Phyllis arrived. We contacted Brent adult protection team and alerted the hosting borough of our concern as part of the multi agency safeguarding procedure. We did not leave a serious concern form as we felt at the end of the inspection safety to people using the service has been restored. We have send a warning letter as part of our enforcement policy to the registered person, and asked them to inform the Care Quality Commission of procedures to be put in place ensuring peoples safety is maintained in the future. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 24, 25 and 30 during this inspection. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service live in comfortable, homely environment. At times there is a slippage of necessary remedial work, which ensures peoples safety. The home is clean, but not free of offensive odour and cleaning materials are not stored safely. EVIDENCE: John Paul House is situated in Willesden North West London, close to local shops, café’s and restaurants. A number of bus stops are outside the home and two underground stations are in walking distance. The home is registered Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 22 for eight people with learning disabilities; during the day of this inspection the home had one vacancy. The home can become quite cramped due to the size of the lounge and the number of people living at John Paul House, but previous registration requirements have been met. All people living at John Paul House have their own bedroom. The home has a large garden, which can be accessed through the kitchen. Over the years people’s mobility has deteriorated and some people find it difficult to access the garden. We required previously that a ramp needs to be built enabling people using the service to access the garden independently. The manager referred the request to the housing association who required and Occupational Therapy assessment. We viewed documentation of an OT referral, stating that they have a waiting list of eleven months and an assessment should be carried out around February 2010. During the day of this inspection the carpets in the hallway have been replaced with linoleum flooring, which is easier to clean and maintain. The registered manager informed us, that carpets and the soft furnishing in the lounge will be replaced. A service user told us that she ordered new sofa’s the day before this key inspection. The registered manager showed us around the building, two people using the service allowed us to see their rooms, which have been nicely decorated and peoples individual tastes are taken into consideration. We noted a strong smell of urine in one of the rooms and advised the registered manager that this must be resolved. The carpet in room 4 had a large hole and the carpet in room 4 was very worn and uneven. This could lead to people using the service having unnecessary accidents and injuries. The home has recently employed a cleaner for 15 hours per week. We spoke to the cleaner who told us that she has received a cleaning schedule, which will ensure that over one week all areas of the home are cleaned. The cleaner did not receive infection control training, which is recommended. The utility room is spacious and a semi professional washing machine and clothes dryer is provided. Staff told us that both machines are in good working order. The home has a cupboard to store cleaning materials; we found the lock to be broken, which made the cleaning materials accessible for people using the service. The registered manager showed us a swine flu management plan. Staff training records show that infection control and Health and Safety training is provided. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 32, 33, 34, 35 and 36 during this inspection. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff is qualified to work with people using the service, but high vacancies and sickness does not always provide a safe skill mix of staff. This leads that at times inexperienced staff support people using the service. Appropriate recruitment checks ensure that people using the service are supported by staff safe to work with vulnerable adults. EVIDENCE: The registered manager told us that she has appointed a new member of staff, who will commence employment once suitable employment checks have been undertaken. The home told us in the AQAA that six out of eleven staff have qualifications in care. This was confirmed by training records viewed during this inspection. Staff told us that they have access to relevant training, training records viewed confirmed this. We spoke to three members of staff during this Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 24 inspection, who demonstrated good understanding of the needs of people using the service. We observed staff interacting with people using the service sensitively, demonstrating good understanding of their difficult communication needs. During the first day of this key inspection (30/09/2009), three staff were on duty. One of the staff was a permanent member of staff who has been working in John Paul House since the end of July 2009. The staff member explained to us that he is experienced in working with people with learning disabilities. He has however not completed his induction training and did not attend any training provided by Dimensions. He informed us that this has been discussed during his first supervision on 08/09/2009. The second member of staff was an agency member of staff who has been working in John Paul House for the second day. The third member of staff was a bank relief worker employed by Dimensions who has been working in John Paul House on and off. During a discussion with the registered manager Dorretta McGregor we were informed that the home has currently one vacancy and four of the senior care workers are currently on Maternity leave or long term sick leave. The rota viewed informed us that four staff are on duty during the morning and four staff are on duty during the afternoon and one member of staff is working during the night, who can be supported by a sleep over staff on the premises. The registered manager told us that a senior member of staff must be on duty during each shift. Staff told us that this is not always the case and the day of the inspection confirmed this. The CQC Provider Relationship manager assessed staffing records kept in the organisations office as compliant. Records of staff employed after April 2008 are kept in a lockable cabinet in the homes office. Appropriate recruitment checks such Criminal Records Bureaux (CRB) checks, two references, employment history, were found to be in place and of good standard. Staff told us that they had a formal interview and had to provide evidence of their identity. We viewed three randomly selected staffing records, certificates of training undertaken was in place. The home forwarded individual training plans to the CQC, which showed that the range of training is varied and suitable to the needs of people using the service. The registered manager informed us that Dimension has introduced E-learning, which can be used by staff. Staff informed us that they had an induction, at the start of their employment. Records of this have been viewed during this inspection. Staff confirmed that they have received a formal supervision from the manager or deputy manager. Staff working at John Paul House over one year have had an annual performance appraisal, were development opportunities are addressed and an action plan is put into place. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 25 Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 37, 39 and 42 during this inspection People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by an experienced manager, there is however a need for the manager to obtain relevant qualifications in Care and Management. Annual stakeholders’ surveys are undertaken ensuring peoples views are taken into consideration. Regular Health and Safety checks are undertaken, which generally ensures people using the service live in a safe place. EVIDENCE: Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 27 The manager has been registered with the CQC predecessor the Commission for Social Care Inspection since 06/01/2009. The manager holds National Vocational Qualification in Care Level 3. She informed us that she is registered to do her Registered Managers Award and National Vocational Qualifications Level 4, but was not clear when the training will commence. During the first day of this key inspection the registered manager was on annual leave, which has been agreed by her line manager. We felt that in view of the maintenance work being undertaken the manager should have been on duty to support the staff team. Or clear guidance and procedures should have been put into place, supporting staff how to deal with the situation if the manager iand senior staff is not available. Staff spoken to did not comment on the support received by the registered manager. The home has undertaken stakeholder’s surveys in 2008, information obtained from the surveys have been analysed and incorporated in the annual development plan. The annual development plan is of good standard, with clear time scales for any actions to be taken. Over the past year staff met formally six times. Records of these meetings are in place and staff told us that they find these meetings valuable. Residents meetings are arranged, but do happen infrequently, this was acknowledged by the registered manager who discussed this with the newly recruited deputy manager. Arrangements have been made for tenants to meet more frequently. The home was visited by the London Fire and Emergency Planning Authority (LFEPA) in January 2007, recommendations made have been actioned. Fire records are of good standard, but more frequent fire evacuation drills are recommended. The home should do four fire drills per calendar year one of this drills should be carried out during night time. A detailed fire risk assessment is in place. The home has been visited by the Environmental Health Department and was awarded a 3 star rating for their kitchen facilities. The Landlord Gas certificate was renewed on 29/09/2009. The registered manager has arranged for portable appliances to be checked. The organisation is undertaking an annual Health and Safety audit, which has been done in January 2009. A member of staff is allocated that regular internal Health and Safety checks are done monthly. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 28 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000062635.V377697.R01.S.doc 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 1 14 2 15 2 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 3 X X 3 X Version 5.3 Page 29 Adepta John Paul House 7-9 Pound Lane 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 YA1 Regulation 6 Requirement The responsible person must update the statement of purpose and service users guide so both documents reflect organisational and regulatory changes. This ensures current and prospective people using the service are issued with up to date information. 2. YA6 15 The responsible person must ensure that changes in how care is provided to people using the service is reflected in their care plan. This ensures people using the service are made aware what care the home provides when they ask for it. 3. YA9 13(4)(c) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Enforcement action is being considered. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 30 Timescale for action 01/11/09 15/11/09 06/11/09 4. YA13 18(1)(a) The responsible person must ensure that there are adequate staff on duty enabling residents to access the community if the choose to do so. Previous timescale of 01/12/08 has not been met 15/11/09 5. YA13 16(2)(m) The responsible person must make sure that activities discussed in care plan meetings and chosen by people using the service happen. This ensures peoples choices are listened to and their needs are met. 15/11/09 6. YA13 17 The responsible person must make every effort that staff clearly record when activities done with people using the services are clearly documented. This allows purchasers, regulators, relatives, staff, the manager to monitor what activities people using the service take part in and if their needs are met. 15/11/09 7. YA14 16(2)(n) The responsible person must support people using the service to go on a seven-day annual holiday. This ensures choices made by people using the service during care plan reviews are actioned. 31/12/09 8. YA15 16(2)(m) The responsible person must 15/11/09 ensure people using the service are supported to visit friends and DS0000062635.V377697.R01.S.doc Version 5.3 Page 31 Adepta John Paul House 7-9 Pound Lane take part in evening clubs if they choose to do so. This provides the opportunity for people using the service to make and maintain relationships with disabled and non-disabled people. 9. YA18 12(1)(b) The registered person shall ensure that the care home is conducted so as to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. This includes the appropriate supervision of any service user who may require support with the use of toilet facilities to maintain their safety and dignity at all times. Enforcement action is being considered. 10. YA19 12(1)(a) The responsible person must ensure staff follows instruction and actions given by health care professionals. This ensures people’s health care needs are met and conditions can be treated appropriately by health care professionals. 11. YA20 13(2) The responsible person must up date the signatory list and include all staff competent in medication administration. This ensures that people using the service are supported by staff competent in the administration of medication. 12. YA23 13(6) The registered person shall make 06/11/09 arrangements, by training staff or by other measures, to prevent DS0000062635.V377697.R01.S.doc Version 5.3 Page 32 06/11/09 15/11/09 15/11/09 Adepta John Paul House 7-9 Pound Lane service users being harmed or suffering abuse or being placed at risk of harm or abuse 13. YA23 13(4)(a) The registered person shall ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Enforcement action is being considered. 14. YA23 13(4)(c) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. Enforcement action is being considered. 15. YA24 23(2)(n) The responsible person must pursue the OT referral and provide a ramp leading to the garden. This ensures that all people using the service can access the garden independently if they choose. 16. YA25 23(2)(p) The responsible person must ensure that the home and rooms are free of offensive odours. This ensures a clean and healthy environment is provided for all people living and working at John Paul House. 17. YA25 23(2)(b) The carpets in room 7 and room 4 must be replaced. This ensures that people using the service can safely move around in their rooms. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 33 06/11/09 06/11/09 01/03/10 01/12/09 01/12/09 18. YA30 23(2)(l) The responsible person must make arrangements that cleaning materials are safely stored and locked away. This ensures dangerous substances can only be accessed by staff and people using the service are not put into unnecessary danger. 01/11/09 19. YA33 18(1)(a) The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working in such numbers as are appropriate for the health and welfare of service users. Enforcement action is being considered. 06/11/09 20. YA37 9(2)(b)(i) The responsible person must ensure that the registered manager is gaining qualifications in care and management. This ensures a skilled and qualified person manages the home and ensures people using the service experience good outcomes of care and leadership. 01/04/10 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 YA6 Good Practice Recommendations The responsible person should re-organise the archive DS0000062635.V377697.R01.S.doc Version 5.3 Page 34 Adepta John Paul House 7-9 Pound Lane folder and remove records which are older then three years from the date of entry. 2. YA17 The responsible person should support people using the service to access sport and fitness activities to maintain and reduce their weight. Medication which is expired or no longer in use should be returned to the dispensing pharmacist for disposal. We recommend to provide infection control and Health and Safety training for the newly employed cleaner. The registered manager or a qualified person should be available at all times to support people using the service. The registered should arrange for more frequent fire evacuation drills. 3. 4. 5. 6. YA20 YA30 YA37 YA42 Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 35 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Adepta John Paul House 7-9 Pound Lane DS0000062635.V377697.R01.S.doc Version 5.3 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!