Inspection on 12/12/05 for Hatton Grove, 4

This inspection was carried out on 12th December 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hatton Grove, 4 27/06/07

Hatton Grove, 4 06/05/05

Hatton Grove, 4 08/11/04

Hatton Grove, 4 08/07/04

Hatton Grove, 4 10/12/03

Hatton Grove, 4 05/09/03

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 Hatton Grove, 4 West Drayton Middlesex UB7 7AU Lead Inspector Paula Eaton Unannounced Inspection 12th December 2005 12:00 Hatton Grove, 4 DS0000032589.V268247.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 Hatton Grove, 4 DS0000032589.V268247.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. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hatton Grove, 4 Address West Drayton Middlesex UB7 7AU 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) 01895 441349 01895 444134 London Borough of Hillingdon Vacant Care Home 17 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (1) of places Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That all window frames be made safe with repair or replacement by 31 July 2005. Care Homes Regulations 2001. Reg 23(2)(b). 6th May 2005 Date of last inspection Brief Description of the Service: Hatton Grove is a purpose built home for seventeen adults with learning disabilities. It opened in the 1970s and is owned and managed by the London Borough of Hillingdon. It is divided into three self-contained flats, one on the ground floor and two on the first floor. The ground floor flat accommodates service users who have physical disabilities as well as profound learning disabilities. There is a passenger lift for access between the ground and first floor. There is a well-maintained garden to the rear of the building. The home is in a residential area close to local shops and amenities. There is also a railway station a short walk from the home and local bus routes available. Hatton Grove, 4 DS0000032589.V268247.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 three hours as part of the annual inspection process. The registered manager had very recently been promoted at the time of the inspection and a senior member of staff was acting up as manager of the home. A senior member of staff, the acting manager and a member of the administration staff assisted with the inspection process. One other member of staff and one service user was spoken to and records, policies and procedures were examined. What the service does well: What has improved since the last inspection? What they could do better: The number of permanent staff members on the home could greatly been improved. Staff had been recruited at the time of the inspection but had not yet commenced work due to delays with recruitment checks. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 6 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. Hatton Grove, 4 DS0000032589.V268247.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 Hatton Grove, 4 DS0000032589.V268247.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 Service users are assessed prior to admission to ensure the home is able to meet their needs. EVIDENCE: Service users had been assessed before being admitted to the home. Care Management needs led assessments had taken place and a copy kept on file. These assessments covered all areas of need and had been used to develop individual care plans. No new service users had been admitted to the home since the last inspection. Hatton Grove, 4 DS0000032589.V268247.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, 7 and 9 Service users needs are reflected in their individual plan. Service users are encouraged to make decisions about day to day living and to take controlled risks within a safe environment enabling them to maintain as much independence as possible. EVIDENCE: The care plans examined were comprehensive documents that covered all areas of need including health, behaviour, religion, involvement in activities and sexuality. Care had been taken to assess each individuals needs with much attention to detail giving the person reading the care plan a real sense of the person being written about. Entries such as ‘place right arm in clothing first when dressing’ show that thought and consideration is given to the comfort of service users. The care plans viewed gave very clear guidelines for staff working with individuals and these documents had been updated and reviewed when required. Each service user has a key worker who is responsible for maintaining these documents. It was evident from the records viewed and from observing staff interacting with service users that service users are encouraged to make choices and Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 10 decisions regarding day to day activities wherever possible. Any limitations on choice were recorded with clear reasons as to why. The care plans viewed clearly aim to encourage service users to be as independent as possible. Contact details for advocacy services are clearly displayed in the home. Comprehensive individual risk assessments were also in place covering a range of issues such as moving and handling, using transport, wandering, bathing and risk of choking. The risk assessments included clear guidelines for staff on how to minimise any risk posed. Hatton Grove, 4 DS0000032589.V268247.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 and 16 A variety of appropriate activities are arranged throughout each week to meet the individual needs and interests of service users including activities that integrate service users into the local community. Service users are encouraged to maintain family relationships and friendships. EVIDENCE: All but one of the service users attends a day centre in the community where various activities are available throughout the day. Individual weekly activity programmes were displayed in the home in a suitable format for service users. The senior member of staff on duty said that service users attend a local club on a Thursday evening and that trips out to lunch, the shops and local parks occur on a regular basis. The senior member of staff on duty also said that each flat had arranged to go out for a Christmas meal. One flat had gone out a week prior to the inspection and another group of service users were going out that night to a local Chinese restaurant. A trip to see a Pantomime at a local theatre had also been arranged for January. The records viewed showed that service users go out into the community on a regular basis. Some service users regularly spend time with their families and friends outside of the home Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 12 and family and friends are encouraged to visit the home and are always welcomed. Staff were observed interacting with service users in a sensitive manner, spending time with those service users who were in their rooms and assisting them with their lunchtime meal in an unhurried manner. There was a pleasant atmosphere in all three flats. Hatton Grove, 4 DS0000032589.V268247.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 and 20 The health needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication procedures in the home are satisfactory. EVIDENCE: Service users preferred routines are recorded as part of their care plan. Individualised support is given to service users and a key worker monitors their care. Staff were observed being sensitive to service users needs and were taking time to ensure that they understood what was being communicated by the service user they were talking to. Each service user record viewed included a health action plan. This included details of current medication, known allergies, any medical conditions, and contact numbers for involved health care professionals. It also included information regarding any health care appointments and any action needed and incorporated regular health checks such as dental, chiropodist and eye tests. Attention had also been paid to well-woman and well-man health issues such as testicular awareness and breast awareness and appointments had been made for the women to have breast screening where appropriate. It was evident from the records that service user health needs were being continuously monitored. Each file viewed also contained a Hospital Assessment form that the home had completed for service users to take to hospital with Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 14 them should they need to go. These documents contained all important information that the hospital would need to know should the service user not be able to tell the hospital staff themselves. For example, medical information and likes and dislikes are included. One service user was in hospital at the time of the inspection as a result of her health deteriorating quite rapidly. The senior member of staff on duty said that the service users needs were in the process of being reassessed to ascertain if the home would still be able to meet her needs. The acting manager said that staff from the home were visiting the service user daily. The medication store and records in flat A were examined. Boots pharmacy provides the medication for the home. The medication in the home was appropriately stored and there were no gaps in the medication administration record sheets. The receipt and disposal of medication was appropriately recorded. None of the service users in the home self medicate. Hatton Grove, 4 DS0000032589.V268247.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): 22 and 23 Systems in the home for dealing with complaints and protecting service users are satisfactory to ensure the protection of service users. EVIDENCE: Since the last inspection the complaints procedure has been updated and now includes contact details for the Commission for Social Care Inspection. The procedure was prominently displayed throughout the home. There had not been any complaints in the home since the last inspection. Since the last inspection staff have received training on the protection of vulnerable adults. The home uses the London Borough of Hillingdon’s protection of vulnerable adults policies and procedures and an up to date copy of these documents was available in the home. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 16 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, 26, 29 and 30 The home provides a clean, comfortable, appropriately adapted and safe environment for service users to live in. EVIDENCE: The home is situated in a quiet cul de sac close to local shops, businesses and transport links. Each flat in the home is suitably furnished and well maintained. The furnishings and décor are domestic in character and provide a comfortable and pleasant environment for service users. Service users individual bedrooms had been personalised and were comfortable and homely. There were pictures displayed and service users were surrounded by their personal possessions. Each bedroom is lockable but staff said that service users choose not to use these locks. The home has appropriate aids and adaptations to be able to meet the needs of service users. There are appropriate grab rails in place and assisted bathing facilities available for service users and service users also have specially adapted beds where necessary. The home was clean and tidy on the day of the inspection. There are appropriate laundry facilities based on the ground floor of the home, which Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 17 were also clean and tidy. Infection control procedures were displayed in the laundry area. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 18 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): 32, 33 and 34 The level of permanent staff in the home is unsatisfactory and does not offer consistency of care to the people using this service. However, staff have been recruited and once in post this issue will be resolved. Service users needs are met by appropriately experienced and trained staff. EVIDENCE: There was a good ratio of staff to service users on duty on the day of the inspection. However, staff rotas show that there is a very high ratio of agency staff being used by the home due to staff shortages. The senior member of staff on duty and the acting manager said that five members of staff had been recruited. One senior member of staff and four care staff. The home was in the process of waiting for all of the recruitment checks to be completed before the new members of staff commenced work at the home. The home has a very experienced and skilled staff team. The acting manager and another senior member of staff are in the process of completing their NVQ level 4 training and the Registered Manager’s Award, three senior members of staff have completed their NVQ level 3 training and one member of staff has just started their NVQ level 3 training. Another two members of staff have completed NVQ level 2 training and another four are in the process of completing it. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 19 The London Borough of Hillingdon deals with staff recruitment for the home. There are robust recruitment procedures in place. The staff records viewed generally contained all of the required information, however, staff references were not available for two members of staff. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 20 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, 39 and42 The management arrangements for the home are satisfactory. There are adequate systems in place in the home to ensure the health, safety and welfare of service users are protected and promoted. However, satisfactory records of these checks are not always maintained in the home. EVIDENCE: The Registered Manager of the home has recently been promoted to the post of Resource Manager and a senior member of staff is acting up in her position. The acting manager is a very experienced senior member of staff and is in the process of completing her NVQ level 4 training and the Registered Manager’s Award. The home has a monthly monitoring system in place to ensure that health and safety matters are addressed. The acting manager provided a draft copy of a questionnaire that had been developed for the relatives of service users using services in the London Borough of Hillingdon. She said that the questionnaire would be adapted to ensure it is relevant to the service provided at the home. She said that the questionnaire would be distributed early next year. Other Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 21 systems are in place to ensure that the practices in the home are regularly monitored. Health and safety maintenance and servicing records were viewed. Equipment used in the home such as hoists and the assisted bathing facilities were being regularly serviced. There was no Landlord’s Gas Safety Certificate available in the home and the most recent Portable Appliance Test certificate was dated January 2004. It was also noted that fridge and freezer temperatures were not always being recorded on a daily basis. Fire safety equipment was being regularly tested and it was evident that fire drills were taking place. However, the frequency of the drills needs to be increased. Appropriate procedures are in place for accident reporting. Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 22 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 X 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 3 X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hatton Grove, 4 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000032589.V268247.R01.S.doc Version 5.0 Page 23 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 YA34 Regulation 19(1)(b) Requirement Timescale for action 01/02/06 2. YA42 3. 4. YA42 YA42 Staff recruitment records must contain all of the information outlined in Schedule 2 of the Care Homes Regulations. 13(4)(a)(c) Al records pertaining to gas and electrical safety checks must be available for inspection and up to date. 23(4)(e) Regular fire drills must take place. 13(4)(c) Fridge and freezer temperatures must be monitored and recorded daily. 01/02/06 01/01/06 12/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Hatton Grove, 4 DS0000032589.V268247.R01.S.doc Version 5.0 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. 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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