Inspection on 29/09/05 for King Edward Road 50

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

King Edward Road 50 04/05/07

King Edward Road 50 07/08/06

King Edward Road 50 20/01/05

King Edward Road 50 10/08/04

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 09/07/2008.

CARE HOME ADULTS 18-65 King Edward Road 50 Barnet Hertfordshire EN5 5AS Lead Inspector Anthony Lewis Unannounced Inspection 29th September 2005 09:10 King Edward Road 50 DS0000010458.V249507.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 King Edward Road 50 DS0000010458.V249507.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. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service King Edward Road 50 Address Barnet Hertfordshire EN5 5AS 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 8364 8282 020 8440 3035 PentaHact Mr Peter John Lord Care Home 5 Category(ies) of Learning disability (5) registration, with number of places King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two specified service users who are over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. 16th May 2005 Date of last inspection Brief Description of the Service: 50 King Edwaqrd Road is a home which provides care and suport to five adults who have a learning disability. The home was opened in 1991. The property is a detached two storey building, which is maintained by Sanctuary Housing Association. PentaHact Housing Association, an organisation that manages several care homes for people with special needs, including learning disability, provide the care. The home is located in a quiet residential area in Barnet. Local bus and tube services and local shops are a short walk from the home. There are four bedrooms on the first floor and one on the ground floor. There is a bathroom and toilet upstairs and a toilet and walk-in shower room located on the ground floor. To the back of the house is a large well maintained garden with flowers and shrubs. There is also garden furniture and barbecue equipment. The front of the house has off street parking. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Thursday 29th September 2005 at 9.10am and was completed at 2pm. The manager was available throughout the inspection and was helpful. Evidence was gathered for this inspection from viewing various safety certificates, documents and files. All five resident’s files were viewed along with five staff files. Two residents were spoken to informally. A tour of the building was conducted with one of the support workers. What the service does well: What has improved since the last inspection? What they could do better: The home’s statement of purpose and service users guide must be updated to reflect the present situation in the home to ensure that prospective residents and present residents have correct information, especially if they need to make an informed choice. Staff must be more vigilant and ensure that they sign for medication when administered. Staff must ensure that all resident’s wishes in the event of their death is recorded. All staff files must contain the information set out in Schedule 2 of the Care Homes Regulations. To ensure that all staff are being supported and their personal development is monitored, they must have regular supervision. The home’s policies and procedures must always be available for inspection. To ensure the safety of residents, staff and visitors, all safety certificates must be available in the home. King Edward Road 50 DS0000010458.V249507.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. King Edward Road 50 DS0000010458.V249507.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 King Edward Road 50 DS0000010458.V249507.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 and 2. Although prospective residents to the home have the necessary information they need regarding the actual moving in process, the home is not insuring that all the information supplied prior to the moving in is accurate and up to date. EVIDENCE: Although prospective residents to the home have information such as the home’s brochure, which sets out the lifestyle and support that they can expect to receive, the statement of purpose and service users guide have not been undated to reflect the present situation in the home as was a requirement at the previous inspection. This requirement is restated. The manager explained the procedure for prospective residents who wish to move into the home. The home also has a moving in policy, which details visits to the home and the requirements prior to moving in. King Edward Road 50 DS0000010458.V249507.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): 8 and 10. Residents are confident that they can have their say in the running of the home and that any information that they may which to discuss to staff will be treated confidentially. EVIDENCE: At resident’s meetings, they are able to air their views and contribute to the running of the home. At the last resident’s meeting on 25th September, residents discussed items on the set agenda such as menu planning, concerns, service delivery and individual issues. All confidential information regarding the residents is kept securely in a locked cupboard in the office. PentaHact has produced a confidentiality policy and procedures guideline, which is kept in the office. Residents and staff have access to the policy and procedures if required. King Edward Road 50 DS0000010458.V249507.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): 14, 16 and 17. Residents are confident that they will be supported by the staff team to engage in appropriate leisure activities and that their rights will be respected by the staff and that the staff will ensure that their dietary needs are met. EVIDENCE: The manager stated that he has recently appointed an activities co-ordinator from the existing support staff team. Information in the home showed that residents regularly attend Springboard day centre, where they engage in various activities. One resident’s file has information regarding her Jewish faith and some of the events and customs associated with Judaism. Throughout the inspection, staff were observed interacting with residents in a courteous and sensitive manner. Residents were observed moving about the home freely without restrictions. The weekly menu was viewed and contained a variety of healthy meals, which are eaten in the kitchen diner. King Edward Road 50 DS0000010458.V249507.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): 18, 20 and 21. The staff team are appropriately supporting residents but they are not ensuring that they follow the correct procedures when administering medication, which is potentially dangerous to residents. Staff are also not ensuring that all of resident’s wishes are recorded. EVIDENCE: One resident’s who exhibits challenging behaviour has, in his personal file, information and guidance for staff on how to support him. Residents seen were clean and well presented. Four of the resident’s Medication Administration Record (MAR) sheets were viewed. There were a number of gaps in the administration sheets where the medication has been administered but has not been signed for or nonadministration coded as to the reason for the non-administration. The gaps were found in regards to administration at various times of the day. A requirement is restated that the registered persons must ensure that all medication administration is signed for and any gaps found are investigated and recorded. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 12 A requirement was made at the previous inspection that all resident’s wishes in the event of them becoming terminally ill or dying are recorded in their file. The manager stated that this has not as yet been completed. This requirement is restated. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 13 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): 23. Residents are confident that they will be safeguarded from all forms of abuse and harm by the homes robust recruitment policies and procedures and are reassured that all incidents will be recorded correctly. EVIDENCE: On looking through five staff files, all had a copy of their Criminal Records Bureau (CRB) check. The home has an accident and incident folder. All incidents have been recorded and reported correctly. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 14 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 and 30. Staff are ensuring that residents live in a clean, safe and comfortable home and that the home is maintained to an acceptable standard. EVIDENCE: A tour of the home was conducted with one of the support workers. All areas were found to be clean, tidy and safe. A workman was observed decorating the homes lounge by painting the walls in warm neutral tones. All areas of the home were found to be clean and tidy and free from any offensive odours. King Edward Road 50 DS0000010458.V249507.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): 34 and 36. The registered providers are not ensuring that residents, staff and visitors are protected by the organisation’s recruitment policies and procedures and are not ensuring that staff’s personal development is regularly monitored. EVIDENCE: Five staff files were viewed and although all contained a Criminal Records Bureau (CRB) check, some files had vital information missing such as a job description and a photograph. One member of staff who transferred from another home, some months ago, did not have his file in the home. A requirement is made that the manager ensures that all staff files contain the information set out in Schedule 2 of the Care Homes Regulations and that the identified member of staff has his file in the home. Although staff are receiving supervision, this is not consistent. Some staff have not had any supervision for the past four months. A requirement is made that all staff working in the home receive regular supervision and the content of the supervision is recorded. King Edward Road 50 DS0000010458.V249507.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): 38, 40, 42 and 43. The registered persons are putting residents, staff and visitors at risk by not ensuring that safety certificates and policies and procedures are in place and are up to date and all identified issues complied with. EVIDENCE: A new manager has been appointed to the home. He stated that he transferred from another PentaHact home in June 2005 and has worked for PentaHact for more than fifteen years. He went on to say that he is at present undertaking the National Vocational Qualification (NVQ) level 4. He stated that he would be applying for registration in the near future. The home’s office was undergoing re-decoration and the walls had been painted very recently and were still drying. Many of the policies and procedures could not be found due to the disruption in the office and therefore could not be viewed. A requirement is made that the registered persons ensure that all policies and procedures are always available for inspection. King Edward Road 50 DS0000010458.V249507.R01.S.doc Version 5.0 Page 17 The home has in place a fire safety and fire risk assessment manual. All fire tests are carried out regularly and a record kept of the outcome. One safety and one test certificate were unavailable for inspection. The manager could not locate the London Fire and Emergency Planning Authority (LFEPA) certificate and the Portable Appliances Test (PAT) certificate. A requirement is made that the registered providers ensure that the LFEPA and PAT certificates are located and a copy of each is forwarded to the Commission. Each resident has information in their file regarding their finances. Files viewed contained resident’s placement agreement, which stated the rent that they pay. Each resident has a petty cash tin, containing their money, which is kept securely in the office. The money in three tins was checked against the resident’s petty cash booklet for recording transactions. All resident’s money checked balanced against what was recorded in the booklet. King Edward Road 50 DS0000010458.V249507.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 1 X X 3 x Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 1 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 King Edward Road 50 Score 3 X 1 1 Standard No 37 38 39 40 41 42 43 Score X 3 X 2 X 1 3 DS0000010458.V249507.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4(2)Sch1 5(1)(2)6 Requirement The registered persons must ensure that the statement of purpose and service users guide are updated to reflect the present situation in the home and a copy of both must be sent to the Commission. (Timescale of 10/06/05 not met). The registered persons must ensure that the administration of all medication is signed for on the (MAR) sheet and any nonadministration coded as to the reason why the medication was not administered. Any omissions in the completion of the administration sheets must be brought to the relevant member of staff’s attention immediately and the outcome recorded. (Timescale of 27/05/05 not met). The registered persons must ensure that resident’s wishes, in the event of them becoming terminally ill and dying, is recorded. (Timescale of 27/05/05 not met). The registered persons must ensure that all staff files contain DS0000010458.V249507.R01.S.doc Timescale for action 18/11/05 2 YA20 13 (2) 14/10/05 3 YA21 12 (3) 23/12/05 4 YA34 19(1)(5d) Sch2 23/12/05 King Edward Road 50 Version 5.0 Page 20 5 YA36 18 (2) 6 YA40 17 (2) Schedule 4 23(2c) (4a) 5 7 YA42 the information set out in Schedule 2 of the Care Homes Regulations and that the identified member of staff has his file in the home for inspection. The registered persons must ensure that all staff receive regular supervision and the content of the supervision is recorded. The registered persons must ensure that the home’s policies and procedures are always available for inspection. The registered persons must ensure that the LFEPA and PAT certificates are located and a copy of each is forwarded to the Commission. 23/12/05 23/12/05 28/10/05 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 King Edward Road 50 DS0000010458.V249507.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 King Edward Road 50 DS0000010458.V249507.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!