Inspection on 21/11/05 for Duchess Close

This inspection was carried out on 21st November 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Duchess Close 16/05/07

Duchess Close 28/02/07

Duchess Close 01/06/05

Duchess Close 21/02/05

Duchess Close 02/09/04

Similar services:

Ashlong House

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Edenvale

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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 Duchess Close 5 & 6 Friern Barnet London N11 3PZ Lead Inspector Tom McKervey Unannounced Inspection 21st November 2005 10:00 Duchess Close 5 & 6 DS0000010425.V265141.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 Duchess Close 5 & 6 DS0000010425.V265141.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. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Duchess Close 5 & 6 Address Friern Barnet London N11 3PZ 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 8362 0920 020 8368 7131 PentaHact Anne Lees Murray Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 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 cul-de-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. There is a good range of shops, pubs and restaurants nearby, and there is good public transport access to the area. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of three and a half hours. The acting manager was present and assisted the inspector in the process. There were six service users living at the home and there were no vacancies. The inspection process involved a tour of the premises, observation of, and discussion with, residents and staff, the acting manager and the deputy manager. The inspector also spoke to a relative of a recently admitted resident. Residents’ and staff files, and records and relating to the maintenance and management of the home were also inspected. What the service does well: What has improved since the last inspection? Some improvements have been made to the maintenance of the property, which were identified at the last inspection. There is better recording of the administration of medicines. A new employer’s liability of insurance has been obtained and portable electrical appliances have been tested. The manager has improved the communication with the residents’ relatives. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 6 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. Duchess Close 5 & 6 DS0000010425.V265141.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 Duchess Close 5 & 6 DS0000010425.V265141.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): 1, 2, 3 & 5 Service users and their representatives are provided with good information and offered informal visits to enable them to make a decision about the suitability of the home. EVIDENCE: The Statement of Purpose accurately reflects the service provided as outlined in Schedule 1 of the National Minimum Standards. The case file of a recently admitted resident contained a comprehensive assessment of their needs, which had been carried out by a care manager and the staff at the home. There was a contract of the terms and conditions of the service, which was signed by the resident. A resident’s relative who was spoken to, said that they had both visited the home for “tea visits”, before deciding on admission. Duchess Close 5 & 6 DS0000010425.V265141.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, 8 & 9 Individual care plans provide guidance for staff about how to meet residents’ needs. Residents are supported to make appropriate decisions within a risk framework, about activities in the community. EVIDENCE: The new resident’s care plan contained assessments, goals and actions, which addressed their needs comprehensively. The inspector participated in a person centred planning meeting, which included the resident, their relative, the key worker and social worker. This was part of an ongoing process of evaluation of the resident’s expectations and how the service could best meet their needs in the future. This process also assessed the risks associated with living in the home and experiences in the community. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15 & 17 Service users enjoy a lifestyle that reflects their individual needs, and are involved in selecting their meals. EVIDENCE: At the time of the inspection, three residents were at day centres and one was returning from a weekend at their family’s home. During the inspection, a member of staff to shop supported a resident. There was evidence in daily logs of residents going out regularly to local amenities. There were examples of written communications being passed between the home and relatives when residents visited their families at weekends. Each resident has an individual menu, which reflects their preferences. The menus were varied and nutritious, and it was noted that two residents were on reducing diets. These residents’ weights are regularly monitored and recorded. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 11 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): 19, & 20 A range of healthcare staff appropriately meets the health and welfare needs of the residents. Medication is being safely administered. EVIDENCE: The new resident was registered with a local G.P. There were good records of their healthcare appointments, including a hospital appointment for minor surgery. This person was also seen regularly by a consultant from the CLDT, (Community Learning Disability Team). The administration of medicines records were accurately completed and the temperatures of the medication cupboards were monitored. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 12 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): There is an appropriate complaints procedure in place, which is being followed. Residents are protected from abuse by appropriate policies and procedures and staff training. EVIDENCE: The home had received one complaint since the last inspection, which was resolved satisfactorily and within a reasonable timescale. Two residents who were spoken to, stated that they were very happy living in the home and they had no complaints. One resident had moved rooms at their request and was happy that their views were listened to. Staff who were spoken to, were knowledgeable about their responsibilities relating to issues of abuse. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 13 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 & 30 Although some improvements have been made to the environment since the last inspection, there are still several maintenance issues to be addressed in order for the residents to have a comfortable, attractive and safe home. EVIDENCE: Birnbeck Housing Association, is responsible for the maintenance of the home. A tour of the premises was carried out. There has been some improvement in repairs and maintenance to the property. However, the following issues were identified: • The curtains in a resident’s room need re-hanging. • Also, in this bedroom, there were several recessed ceiling lights, but only one worked. • Both kitchens need decorating, and in one kitchen, there was a hole in the ceiling where an electric cable exited. • The seals around the kitchen sinks need to be redone and some kitchen units were broken. • The sinks are damaged and should be replaced. • The exterior of the property needs redecorating. (This was a requirement at the last inspection). Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 14 At the time of the inspection, the home was clean and tidy. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34 & 36 Staff are knowledgeable about their roles and about the needs of the residents and they are properly supervised. The records of a member of staff were not available for inspection. This is not acceptable because these records provide evidence about the recruitment process in relation to the protection of residents. EVIDENCE: Two staff who were spoken to, were able to describe their roles in caring for residents. This involved acting as key workers for specific residents and being responsible for constructing care plans. One member of staff had been recruited recently. However, at the time of the inspection, the manager was unable to locate the file, so this standard was not inspected. A requirement is made regarding this matter. The staff who were spoken to, confirmed that they received regular supervision, which they described as a support in carrying out their duties. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 16 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 & 42 This is generally, a well run home where there is good leadership provided by the present manager. The process of the imminent change of managers is being properly conducted to cause least disruption to the residents and staff. EVIDENCE: The inspector was informed that the present manager was leaving his post at the end of December. However, a new manager had already been agreed. The manager described the process of replacing his post and stated that an appropriate handover would take place, including communicating the change to residents, relatives and staff. This should enable a smooth transition of responsibilities. This is especially important, given the nature of the residents’ disabilities, visà-vis acceptance of major changes in their lives. The manager stated that, since the last inspection, he had met with all the relatives to ensure that there was good communication between both parties. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 17 It is important that the new manager carries out the same process, when they take up post. In relation to health and safety issues; Food was stored safely and temperatures of fridges and freezers were monitored. The fire logs showed that alarms were conducted weekly and fire drills were carried out. Electric portable appliances had been tested since the last inspection. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 18 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 3 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Duchess Close 5 & 6 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 X DS0000010425.V265141.R01.S.doc Version 5.0 Page 19 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 YA24 Regulation 23(2)(b)(d) • Requirement The Registered Person must ensure that: The curtains in a resident’s room are rehung, and all the ceiling lights are working. Both kitchens are redecorated, and the hole in the kitchen ceiling is repaired. The seals around the kitchen sinks are replaced and the kitchen units are repaired. The kitchen sinks are replaced. Timescale for action 31/01/06 • • • 2. YA24 23(2)(b)(d) The Registered Person must ensure that the exterior of the property is redecorated. (This was a requirement at the last inspection). The previous timescale was 31/08/05. 19(5)(a) The Registered Person must ensure that complete staff records are always available for inspection at the home. 31/03/06 3 YA34 31/12/05 Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 20 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 YA38 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. Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 21 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. Extracts may not be used or reproduced without the express permission of CSCI Duchess Close 5 & 6 DS0000010425.V265141.R01.S.doc Version 5.0 Page 22 - 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. 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