Inspection on 04/10/05 for Booth Road 82

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Booth Road 82 18/08/08

Booth Road 82 11/04/07

Booth Road 82 26/07/06

Booth Road 82 28/04/05

Booth Road 82 07/04/04

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 Booth Road 82 Colindale London NW9 5JY Lead Inspector Tola Akinde-Hummel Unannounced Inspection 4th October 2005 09:00 Booth Road 82 DS0000010411.V251055.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 Booth Road 82 DS0000010411.V251055.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. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Booth Road 82 Address Colindale London NW9 5JY 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) 020 8200 8504 020 8200 8504 www.pentahact.org.uk PentaHact Care Home 8 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 4 adults who have a learning disability (LD) and who may also have physical disabilities (PD) and have associated nursing needs. Specific Service User One specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. 28th April 2005 Date of last inspection Brief Description of the Service: 82 and 84 Booth Road were previously two homes which have now been amalgamated and operate as one home with a manager and two deputy managers. The stated aim of the home is to provide twenty four hour care and support for people with profound learning disabilities to enable them to live as independently as possible within the community. The home consists of two adjoining semi detached houses. On the ground floor of each house is a lounge, kitchen diner, toilet and laundry room. On the first floor, there are walk in showers, an assisted bath with a toilet and four bedrooms. On the second floor there is an office shared by both houses, a storage room and a meeting room. There is a small parking area at the front of the home and a garden at the back. The garden is partly paved and shaded and is accessisible to service users. The home is situated close to Colindale station on the Northern line. It is a short walk to Colindale Hospital and approximatey a mile away from Edgware Hospital. It is close to shops, restuarants and public transport facilities located along the Edgware Road. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took six hours to complete. Four service users seen at home during the course of the inspection. The inspector was able to speak to one service user very briefly. Two service users have limited verbal communication and one service users declined to speak to the inspector. The inspector spoke to three members of staff and was assisted by the manager Mrs Christine Balachandre during the inspection. The inspector looked at the storage and recording of medication, training profiles, team meeting minutes, supervision records, health and safety records, including records of fire drills, and care plans and risk assessments. There was two staff supporting service users in the morning during the inspection in each house. There is currently one vacancy in the home. The home is short of two permanent staff vacancies following their suspension. Agency staff currently cover these posts until the situation is resolved. The inspector would like to thank all staff and service users who made themselves available during the inspection. What the service does well: What has improved since the last inspection? Whilst it was not observed at this inspection, the manager states that all staff sit beside service users who are assisted with meals as required at the previous inspection. Medication records show that the recording of returned medicines is properly documented minimising the risk of errors. Efforts have Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 6 been made to clean the kitchen cupboards however these need replacing due to wear and tear. The home successfully employed a part time cleaner to assist with ensuring hygiene in the home is maintained. Staff now label all food stored in cupboards and the fridge. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Booth Road 82 DS0000010411.V251055.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 Booth Road 82 DS0000010411.V251055.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): 2,5 Service users needs and aspirations are assessed in detail. This means that service users can expect staff to be clear about the best ways in which to assist them to develop both personally and socially. EVIDENCE: There have been no new admissions to Booth Road since the last inspection. All service users that have entered the home have detailed pre admission assessments supported by medical reports outlining their health needs. All service users have a statement of terms and conditions on their files. These are user friendly and signed by service users or their representatives. Booth Road 82 DS0000010411.V251055.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): 6,9,10 Service users changing needs are well documented. Any change is implemented and monitored. This results in service users being confident that their needs and wishes for independence are understood and staff act in the service users best interests. EVIDENCE: The quality of plans of care at Booth Road remains high. These plans are detailed and include methods of communication used by service users, all aspects of service users behaviour and how this is managed, service users activities timetable, relationship maps and other information relevant to building a holistic picture of service users. The plans seen are reviewed and amended regularly as needs change. As confirmed at the previous inspection, service users continue to complete household tasks as they wish and are encouraged to develop these skills as appropriate. This includes meal preparation, table setting, shopping and laundry. One service user particularly enjoys doing her own laundry, however there are risks associated to this. All service users have detailed risk assessments which Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 10 staff are familiar with. These ensure that the balance of independence and risk is managed appropriately. The records kept relating to service users are maintained in a lockable office, which is accessible only to staff. Booth Road 82 DS0000010411.V251055.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): 12, 13,14, 15, Service users continue to exercise choice with regards to their personal, social and educational development where appropriate. This results in service users being adequately stimulated inside and outside the home. EVIDENCE: Service users continue to have a variety of activities available to participate in. These include attending college, swimming and social clubs. Service users with limited communication are stimulated by one to one contact with staff and engage in activities appropriate to their abilities and interests. Service users also have music therapy and aromatherapy sessions in the home. The cultural mix of staff does not accurately reflect the service users living there however; great effort is made to ensure that the cultural needs of service users are met. This is made possible with clear information in service users care plans about areas such as religion, dietary preferences and preferred social activities. The staff team draws upon its European, African- Caribbean, and Asian background to provide a culturally sensitive service. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 12 Staff accompanied three service users on holiday to Bognor Regis for four nights. Risk assessments were put in place prior to the trip. The trip was needs led ensuring that the holiday focused on service users wishes. Service users were supported on a one to one basis. One member of staff said that the holiday was a success. All service users had their own rooms and assistance with personal care was provided as outlined in their care plans. One service user told the inspector about the holiday and said how much she enjoyed this. Service users who have relatives are supported to maintain contact and all visitors are welcomed to the home. The visitors’ book confirmed that visitors enter the home at varying times. During the inspection service users were asked what they would like for lunch others were told what was available to encourage service users with less verbal abilities to make choices. These meals were then prepared for them. Whilst service users were not observed being fed the manager assured the inspector that all service users who require assistance at mealtimes are given this seated with service users as required at the previous inspection. Booth Road 82 DS0000010411.V251055.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): 18,19,20 Booth Road staff work effectively with service users and other professionals. Therefore,service users in the home continue to be provided with sensitive personal and health care support by staff. EVIDENCE: Three service users plans were examined in detail. The information is comprehensive and easy to follow. Records of all medical appointments including gynaecology and urological health issues are explored. Records show that where there are changes in a service users needs these are reflected in their plan of care. This is done in consultation with relevant specialists such as the epilepsy nurse and psychiatrist. Up to date information is placed on files and made available to all staff that must read and sign to confirm they understand the new plan of care to be followed. Service users have regular reviews of their care plans; again these are detailed, signed and dated. One service user with particularly difficult health issues is supported to maintain her independence and make choices about aids available to minimise any risk to her health. This is reviewed in a multi disciplinary setting. Service users plans make clear their preference about the gender of staff members that will assist them with personal care. There are extensive risk Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 14 assessments on all service users files, which cover all aspects of service users lives. Medication records were inspected and were in order. The record of medication returned to the pharmacy now complies with the standard. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 15 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): Service users have access to information should they wish to make a complaint. The policies and procedures are robust and that staff are familiar with them. This ensures abuse is recognised and where possible prevented from occurring. EVIDENCE: Service users were unable to advise the inspector of their opinions in relation to the complaints process. However the pictorial communication system advises service users how they can make a complaint. This is included in the service users guide. The complaints record showed that there have been no complaints since the last inspection. There have been a number of accidents and incidents since the last inspection. These have been documented and where necessary have been forwarded to CSCI. Booth Road must ensure that all records of incidents are dated. Booth Road has an adult protection policy and procedure that operates alongside Barnet Councils Adult Protection procedure. Training records indicate that some staff attended recent adult protection training in July 2005. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 16 Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28,30 The home does not consistently promote good hygiene in the toilet and kitchens in the home. Attention to this will enable service users to use these facilities safely and minimise any risk of ill health. EVIDENCE: The furniture in Booth Road is domestic in size and gives a homely appearance to the communal areas. The rooms are wheelchair accessible, large, bright and adequately decorated. This applies to both units that are split into two units of four. The premises have a lift making the whole home accessible to all service users. There have been a number of difficulties with the lift breaking down minimising access to the lower floors for service users using wheelchairs and others unable to use the stairs safely. This has now been rectified. The home is close to bus and underground routes and local amenities are close by. At the time of inspection, one toilet on the ground floor did not have any liquid soap or hand towels available. The pedal bin in the toilet was also broken. It is important when promoting good hygiene, there are adequate supplies available to staff and service users. At the last inspection requirements were made to ensure that the cooker hoods in both kitchens are free of grease and that the kitchen cupboards are clean. The requirement for the cupboards to be cleaned has been met but the impact Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 18 of this is limited. The cooker hoods continue to be greasy and unhygienic. This requirement has not been met. The kitchen units cannot be cleaned properly due to the age of the units, which show signs of serious wear and tear. They no longer close properly and are chipped in many areas. These units should be replaced. This would ensure they are hygienic and safe for service users to store food. The requirement to review the need for a cleaner in the home has been completed and a part time cleaner is employed. The homes control of infection policy has not been reviewed for some time. This must be reviewed to ensure it remains relevant and that staff are familiar with it. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 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): 33, 34,36 The recruitment procedure is robust. This minimises the risk of inappropriate appointments being made and service users being placed at risk. The training and supervision of staff is regular enabling the home to deliver quality care to service users. EVIDENCE: The home has some experienced staff dedicated to providing the best care and support to service users. Staff contribute to the functions of the home in a variety of ways, these include assisting service users with personal care, completing domestic and household chores and completing administrative tasks. Presently, two staff members are undergoing the homes disciplinary procedure. This has upset the staff team but is being managed in well. Existing staff receive ongoing support from the manager to ensure a professional service is maintained. The ongoing disciplinary has an impact on staffing levels and the manager is covering the shortfall with agency staff that have worked in the home before. One new member of care staff has been recruited since the last inspection. Records show that the staff member was recruited correctly. An application form was completed, an interview conducted, two references were obtained, a criminal records check was completed prior to employment and at least two Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 20 forms of identification are evident. The staff member received an induction following appointment. There have been approximately seven different types of training on offer for staff since the last inspection. Records show that most staff have completed some of the training on offer. The training includes First Aid appointed person, medication training and essential food hygiene. Four staff records confirm that they receive regular supervision by senior members of the staff team. Supervision includes ensuring that staff continues to provide appropriate support to service users, and are familiar with any new policies and procedures. Staff also benefit from discussing their own personal development. The recording of supervision is not completed on Pentahact supervision paperwork. This should be done to remain consistent with organisational procedure. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 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): 37,38,40,42 A competent manager leads the home. Service users benefit from well planned support. This makes life in the home calm and organised. A review of procedures and legionella testing must be undertaken. EVIDENCE: The manager, Mrs Christine Balachandre demonstrates competency in her management of the home. One staff member said “The manager as very supportive and always ready to talk to you if you have any problems”. The manager ensures that all the homes policies and procedures are read and understood by staff. These are discussed in staff meetings. There is open communication between the staff and the manager, and staff are clear about the manager’s expectations in relation to the smooth running of the home. The manager has recently spoken at a conference looking at diversity in the workforce and raising awareness about some of the issues Pentahact come across as an organisation. This has proved useful and the manager will continue work on this issue in the organisation. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 22 The infection control procedure has not been reviewed for some time. This must be completed to ensure it remains up to date and relevant. Booth Road had an independent finance audit in July 2005, some minor financial control procedures were recommended and these have been put in place. Booth Road had a Fire risk assessment in July and a company employed by Pentahact has inspected this, further recommendations have been made. The fire tests continue to take place in the home. The home does not have a current Legionella test certificate. This must be done to confirm the safety of the water supply. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 2 1 X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Booth Road 82 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X 2 X DS0000010411.V251055.R01.S.doc Version 5.0 Page 24 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 YA27 Regulation 23(c) Requirement The registered person must ensure that all toilets are provided with liquid soap, paper hand towels and a pedal bin in working order at all times. The registered person must ensure that the kitchen units in both houses are replaced. The registered person must ensure that the cooker hoods in both houses are kept clean and grease free and that this is maintained. (Previous timescale 30/05/05 not met). The registered person must review the control of infection procedure to ensure it remains relevant. The registered person must ensure that a Legionella test is completed in both houses. Timescale for action 16/11/05 2 3 YA28 YA30 16(2)(h) 23(c) 13 (4)(c) 16 (2)(h) 01/05/06 16/11/05 4 YA40 13 (3) 30/12/05 5 YA42 13 (4)(c) 02/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 25 No. Refer to Standard Good Practice Recommendations Booth Road 82 DS0000010411.V251055.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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