Inspection on 01/06/05 for Duchess Close

This inspection was carried out on 1st June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Duchess Close 16/05/07

Duchess Close 28/02/07

Duchess Close 21/11/05

Duchess Close 21/02/05

Duchess Close 02/09/04

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Chatsworth Care - Tudor Lodge

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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 5 & 6 DUCHESS CLOSE Friern Barnet London N11 3PZ Lead Inspector Tom McKervey Announced 1 June 2005 @ 09.30am 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 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 Stationary 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. 5 & 6 DUCHESS CLOSE Version 1.10 Page 3 SERVICE INFORMATION Name of service 5 & 6 Duchess Close Address 5 & 6 Duchess Close, Friern Barnet, London N11 3PZ Telephone number Fax number Email 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 8362 0920 020 8368 7131 Cedric Frederick for PentaHact Vacant PC Care Home only 6 Category(ies) of LD Learning Disability registration, with number of places 5 & 6 DUCHESS CLOSE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21 February 2005 Brief Description of the Service: 5 and 6, Duchess Close, is a residential care home for six adults, male and female, who have a learning disability with an autistic spectrum disorder. The home was first registered in November 2000, and was established in partnership with Birnbeck Housing Association and Barnet Council. The home, which was built as part of a larger general needs housing development, on the old Friern Barnet Hospital site, is situated in a quiet culde-sac. The property is comprised of two adjoining semi-detached houses, with through-access on the ground floor. This arrangement provides separate group-living areas, each with their own kitchen-diner, lounge, toilet and bathroom. There is a bedroom on the ground floor, and two first-floor bedrooms, in each house. There is space for car parking at the front, and a large garden at the rear of the property. Nearby, there is a good range of shops, pubs and restaurants, and there is good public transport access to the home. 5 & 6 DUCHESS CLOSE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over a period of five hours, forty-five minutes. The acting manager was present and assisted the inspector in the process. There were five service users living at the home and there was one vacancy. The inspection process involved a tour of the premises, observation of, and discussion with, service users and staff, the acting manager and the deputy manager. A relative was also interviewed by telephone. Service users’ records and documents relating to the maintenance and management of the home were also inspected. Comment cards form a relative and a professional connected to the service, were sent to the inspector prior to the inspection. What the service does well: What has improved since the last inspection? Service users’ care plans have been improved in providing timescales for achieving care objectives. A new, experienced manager has been appointed, and staff supervisions is now provided regularly. Fire safety procedures have been improved by having fire drills for service users and staff. The service users’ lounges are more homely. 5 & 6 DUCHESS CLOSE Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 5 & 6 DUCHESS CLOSE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 1, 2 & 5 Potential service users and their representatives are provided with appropriate information to enable them to make a decision about the suitability of the home. EVIDENCE: The Statement of Purpose has been amended to reflect the recent changes in the management structure of the home. There was evidence in the two case files examined, that comprehensive assessments of service users’ needs had been carried out by care managers and the staff at the home. The records of the most recently admitted service user contained a contract of the terms and conditions of the home. The document was signed by the service user. 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 6, 7, 8, 9 & 10 There are good systems in place for consulting service users about the running of the home, with evidence that service users’ views are sought and acted on. EVIDENCE: Two care plans were sampled. They contained assessments, appropriate goals and guidance for staff about required actions. The care plans had been reviewed within the last six months. Two service users who were spoken to, described how they were enabled to make decisions about their lives. For example; one service user decided to change some activities at the day centre. Another service user decided to move to another bedroom, and described the preparations they were making for the move. One service user is none-verbal. However, a range of symbols and objects of reference were available for this service user to communicate decisions and choices. For example; the inspector noted that when a hot or cold drink was required, a blue or red cup was indicated. Service users informed the inspector that, with the support of the staff, they were involved in the shopping and cooking. The minutes of regular service user and staff meetings were seen, at which, service users were consulted about the running of the home. 5 & 6 DUCHESS CLOSE Version 1.10 Page 10 The case files contained a range of risk assessments for each service user. The acting manager stated that a programme was being devised for one service user to enable him to use public transport, within a risk assessment framework. Two staff who were spoken to, were able to demonstrate awareness about the need for confidentiality. Important documents and service users’ records were stored securely. 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 11, 12, 13, 14, 15, 16 & 17 Service users enjoy a lifestyle that reflects their individual needs and aspirations. Service users are treated in an adult manner, which allows them to develop and maximise their potential as members of the local community. EVIDENCE: Interviews with two service users indicated that service users are enabled to enhance and develop skills within the home and through attendance at day centres. One service user stated that he uses a computer at the day centre. Another service user attends college. Service users partake in shopping and cooking and were observed making their own drinks. There was evidence in daily logs of service users going out regularly to local amenities. Three service users went to the local pub on the day of the inspection. The inspector was invited by a service user to sit in on a discussion with her key-worker about planning to change bedrooms at the weekend. The inspector was impressed at how the detailed planning and the responsibility for this 5 & 6 DUCHESS CLOSE Version 1.10 Page 12 move was communicated to the service user, in a painstaking and patient manner. There is an appropriate policy about sexuality and relationships in place. The menus reflected each service user’s individual likes and dislikes, whilst still ensuring that a wholesome, balanced diet was provided. Fresh fruit was available, and service users stated that they are consulted about the menu at a weekly meeting. There was evidence that a dietician was involved in planning a weight-reducing regime for one service user. Kosher food was provided for one service user. 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 19 & 20 The health of service users is being met by a range of healthcare professionals. However, the administration of medicines is not always carried out thoroughly, in a manner that assures the safely and welfare of service users. EVIDENCE: Two case files seen, showed that service users’ healthcare needs were being met by a range of healthcare professionals; e.g., G.P’s, dentists and opticians. There is evidence of good links with the community learning disability team. The accident book indicated that accidents were appropriately recorded. There was an appropriate medication policy in place. One service user had been assessed to self-administer medication, which was well documented. It was noted that there were some gaps in the administration of medicines records, where staff had not signed. 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 22 & 23 Service users are protected by appropriate policies and procedures and staff training. However, the home’s complaints procedure is not being followed to ensure that service users’ and their representatives’ complaints are always recorded and addressed. EVIDENCE: Service users who were spoken to, stated that they were very happy living in the home and they had no complaints. They stated that their views were listened to at the weekly residents’ meetings. Prior to the inspection, the inspector spoke to a relative who had sent comments to the Commission for Social Care Inspection. The comments were generally very positive about the service. However, the relative stated that there were times when the service user was unclean and not well-dressed when going on home visits. The relative stated that they had complained to staff about this at the time, but there was no record of this in the complaints book. The matter of ensuring that all complaints are logged, was brought to the attention of the acting manager. The staff who were spoken to, were very knowledgeable about issues of abuse and were acquainted with the Whistle-blowing procedure. There was evidence that training in adult protection from abuse was provided. 5 & 6 DUCHESS CLOSE Version 1.10 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 standard(s) 24, 26, 27, 28 & 30 This home is not being properly maintained, preventing service users from living in a homely and attractive environment. EVIDENCE: Birnbeck Housing Association, is responsible for the maintenance of the home. A tour of the premises was carried out. It was evident that the home was poorly maintained. For example: There were weeds growing through the block paving at the front of the home, and the exterior woodwork needs repainting. The garden was unkempt and the grass needed cutting. The carpet leading to the conservatory and garden area was worn and very stained. In both sections of the home, there were further deficits identified in the bathrooms and toilets. Requirements have been made to address these issues. The lounge areas, although rather sparse of pictures and other decorations, had recently been made more homely. The inspector was informed that bedrooms and lounge areas were decorated in accordance with service users’ wishes and in keeping with their disabilities. 5 & 6 DUCHESS CLOSE Version 1.10 Page 16 One service user’s bedroom was seen. It contained a comfortable bed and armchair, and a lockable cabinet for keeping valuables. There were personal possessions in the room. With the exception of the corridor carpet as noted above, the home was clean and tidy and there were no offensive odours. 5 & 6 DUCHESS CLOSE Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 & 36 Service users are supported by a well trained and supervised team, who are committed to providing a good quality of service. There are generally safe systems in place for recruiting staff, but in one case, an appropriate Criminal Records Bureau,(CRB), and Protection of Vulnerable Adults, (POVA), clearance had not been obtained. EVIDENCE: A comprehensive training record was available for inspection. In addition to induction and foundation courses, training in epilepsy, mental health, Aspergers syndrome and autism was also provided. The staff rotas were flexible, and showed that sufficient staff were always available to meet service users’ needs at particular times; for example, when outings were planned. The records of four staff were sampled. They contained evidence that staff were properly recruited and satisfactory CRB and POVA checks were made. However, one staff’s CRB certificate related to another post and service in Pentahact, which is not transferable. The records showed that three staff had NVQ’s, and the acting manager stated that eight other staff were starting the training in June 05. Supervision records were seen. Two staff who were spoken to, stated that they found supervision valuable. One person stated, “I can talk about anything to 5 & 6 DUCHESS CLOSE Version 1.10 Page 18 my line manager in supervision. I was well supported by staff to stay in this job, when I first came, and supervision helps me in my work.” 5 & 6 DUCHESS CLOSE Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 41, & 42. This is generally, a well run home with good leadership being provided by the acting manager, and there is a good system in place for keeping records. However, there is a need for better communication by the acting manager with service users’ relatives. EVIDENCE: It was noted that the home had undergone many changes of staff personel, including the previous manager. However, the inspector found that the change process was managed satisfactorily, with no apparent major disruption in the service. The current acting manager has the required experience of running a home, as he was previously a registered manager for another Pentahact home. He had been in charge of the home since March 05, and has recently applied for his registration for Duchess Close. Service users and staff who were spoken to, expressed confidence in the acting manager’s ability to run the home efficiently. The acting manager was 5 & 6 DUCHESS CLOSE Version 1.10 Page 20 regarded as approachable and supportive. However, a relative to whom the inspector spoke on the telephone, complained that there was a lack of communication between the acting manager and relatives. The complainant stated that no meetings had been held by the new manager with relatives, and there were changes of key workers and other issues which had not been communicated appropriately. When the inspector informed the acting manager about these matters, he agreed to arrange a relatives’ meeting in the near future. The minutes of staff and service users’ meetings, indicated that their views about the running of the home were sought and acted on. Policies about sexuality and administration of medicines were found to be appropriate. Two service users’ personal cash tins were examined and found to match the balance in the records. There is a good standard of record keeping. Staff and service users’ records and other important documents were kept securely. Staff records showed that they had received training in health and safety, and fire, gas and electricity safety certificates were seen. However, portable electrical appliances had not been tested. An action plan, which covered staff training, budget monitoring, maintenance and health and safety issues for 2005, was available for inspection. However, it was noted that the employer’s liability insurance certificate was out of date. 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 5 & 6 DUCHESS CLOSE (Commendable) 3 Standard Met Version 1.10 (No Shortfalls) Page 21 2 Standard Almost Met (Minor Shortfalls) 1 Standard Not Met (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 3 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 3 2 3 x 2 Standard No 11 12 13 14 15 16 17 4 3 3 3 3 4 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 2 5 & 6 DUCHESS CLOSE Version 1.10 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13(2) Requirement The Registered Person must ensure that signatures are obtained for all administered medicateion. The Registered Person must ensure that all complaints about the service are logged. The Registered Person must ensure that: 1.The weeds are cleared from the front driveway. 2. The carpet leading to the conservatory is cleaned or replaced. 3. The garden is properly maintained. 4. The exterior woodwork is repainted. 5. In the toilet and bathroom areas, seals and broken tiles are replaced, and the ceilings are repainted where stains occur. The Registered Person must ensure that current CRB/POVA are obtained for all new staff in the home. The Registered Person must ensure that portable electrical appliances are tested yearly. The Registered Person must ensure that a current employers Version 1.10 Timescale for action 30/6/05 2. 3. 22 22(3) 30/6/05 31/8/05 24, 27 & 30 23(2)(b)( d) 4. 34 19(5)(a) 30/6/05 5. 6. 42 43 13(3) 25(1)(e) 31/7/05 31/7/05 5 & 6 DUCHESS CLOSE Page 23 liability certificate is provided at the home. 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 38 Good Practice Recommendations The acting manager should hold regular meetings with representatives of service users to ensure good communication and listen to and act on, their views. 5 & 6 DUCHESS CLOSE Version 1.10 Page 24 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI 5 & 6 DUCHESS CLOSE Version 1.10 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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