Inspection on 06/02/06 for Matlock Close 4

This inspection was carried out on 6th February 2006.

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

Matlock Close 4 16/03/09

Matlock Close 4 24/04/08

Matlock Close 4 04/12/07

Matlock Close 4 20/06/07

Matlock Close 4 11/09/06

Matlock Close 4 21/07/05

Matlock Close 4 17/01/05

Matlock Close 4 17/08/04

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 Matlock Close 4 Barnet Hertfordshire EN5 2RS Lead Inspector Anthony Lewis Unannounced Inspection 6th February 2006 09:00 Matlock Close 4 DS0000010536.V271056.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 Matlock Close 4 DS0000010536.V271056.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. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Matlock Close 4 Address Barnet Hertfordshire EN5 2RS 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 8449 9053 020 8449 9053 spower@pentahact.org.uk PentaHact Miss Sandra Power Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 8 adults who have a learning disability (LD), and who may also have a physical disability (PD). 21st July 2005 Date of last inspection Brief Description of the Service: 4 Matlock Close is a large purpose built detached bungalow for eight adults with learning and physical disabilities and designed for residents who use wheelchairs. The home is situated on a substantial plot with gardens to the sides and rear. There is off street parking to the front of the home for several vehicles. The home was opened in May 1995 and is managed by PentaHact who provides care and support to people with special needs and maintained by Notting Hill Housing. The home is situated on a relatively new housing estate in High Barnet, a short walk from the local bus routes and local shops and a short bus journey to Barnet town centre. Barnet General Hospital, Whalebone Park and primary schools are within a short walk of the home. Matlock Close 4 DS0000010536.V271056.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 Monday 6th February 2006 at 9am and was completed by 3.40pm. The new registered manager Jane Devine, was available throughout the inspection process and was very helpful and accommodating. Evidence was gathered for this inspection by talking informally to one resident and formally in private to three staff members. One resident’s father was also spoken to in private. All residents’ and five staff files were viewed. In addition various policies and procedures, documents, files and certificates were viewed. An internal and external tour of the home was conducted with the registered manager. All of the core standards were inspected over the two inspections for the year. Overall, the residents are receiving a good quality service. The newly registered manager and the staff team have ensured that the five requirements from the previous inspection have been met. All areas of the home are kept clean and tidy and decorated to a good standard. Residents are being cared for by a staff team who have a good understanding of the residents’ individual and collective needs and ensure that they work well as a team to improve the quality of service. What the service does well: What has improved since the last inspection? Five requirements were made at the previous inspection. The collective efforts of all of the staff team have ensured that all of the requirements were met. Residents’ wishes in the event of them becoming terminally ill and dying are recorded in their care plans. The staff team are ensuring that none of the doors in the home are wedged open. Recruitment procedures have been reviewed and all staff have two references. The home has a business and development plan. All residents’ money is accounted for on a daily basis. Matlock Close 4 DS0000010536.V271056.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. Matlock Close 4 DS0000010536.V271056.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 Matlock Close 4 DS0000010536.V271056.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. Prospective residents, their family and representatives are not being provided entirely with up to date information about the home. Robust assessments of individual resident’s needs are being carried out to ensure that their needs can be met. EVIDENCE: The statement of purpose and service users’ guide were viewed and although quite comprehensive, both contained the named and details of the previous registered manager. A requirement is made that the statement of purpose and service user’s guide are revised. The staff team have ensured that health care professionals have been involved in the assessment and implementation of resident’s care plans. Information in resident’s care plans show that a speech and language therapist and an occupational therapist have assessed resident’s regarding their communication methods and equipment for their individual care needs. A joint report compiled by the home and speech and language therapist was seen and contained information on the way in which individual residents communicate, their level of social interaction and the recommendations from the report, which staff have implemented. Matlock Close 4 DS0000010536.V271056.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 and 10. Although staff are ensuring that residents are consulted with regarding the running of the home, they are not ensuring that residents are supported in identifying and achieving their personal goals. EVIDENCE: Although residents have relatively good care plans, on looking through three of them, there was a lack of information regarding what are the personal goals or ambitions that the resident, their family or representative have identified. There is information on goals such as health, bedroom decorating and transport to and from their day activities but according to the registered manager, these goals were identified by staff and health care professionals and not residents and do not reflect the residents individual wishes and are quite impersonal. A requirement is made that residents are supported in identifying their personal goals and that they are recorded in their care plans. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 10 Regular residents’ meetings occur in the home, to ensure that residents have their say in the running of the home. At a meeting held on the 29th November 2005, staff discussed with residents: moving and handling methods, the money that will be spent on communal furniture, the recent review of the service by the operations manager and the completion of service user and family questionnaires. A relative spoken to said that the home writes to him from time to time regarding family meetings to discuss the continual development of the home. He went on to say that he has attended these meetings on occasions. Residents’ personal information is kept in lockable cabinets in an office, which is kept locked when not in use. Matlock Close 4 DS0000010536.V271056.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): 11, 14, 15, 16 and 17. Residents’ personal development is only being partially met because staff are not ensuring that residents engage in sufficient leisure activities. Residents’ rights are being respected and they are being supported to maintain family links. EVIDENCE: Residents’ files contained information on how staff will support residents to meet their cultural and spiritual needs. Some residents files contained information on them wishing to attend church. In the staff communication book, there was information on three residents attending church, with staff support on 5th February 2006. Five residents’ files were viewed and although there was information on their leisure activities, these were limited to day activities such as attending a day centre, shopping or spending the day with their family. There was insufficient information regarding evening leisure activities for any of the residents. A requirement is made that residents are supported to access leisure activities at all times if requested. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 12 Resident’s files and review records show that their relatives are active in their life and provide advice and help where necessary. On arrive at the home a resident was preparing to go out with their father for the day. On arriving back, the resident’s father was spoken to in private. He said that he visits every Monday. He went on to say that he accompanies his relative on holidays once a year. Throughout the inspection staff were indirectly observed knocking on resident’s bedroom doors prior to entering and calling them by their first name. Interaction between residents and staff was observed to be relaxed and courteous at all times. The menu for the past six weeks were viewed and showed that residents are receiving a variety of wholesome and nourishing meals. One resident spoken to said, “I like the food in the home”. Matlock Close 4 DS0000010536.V271056.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, 20 and 21. The staff team are ensuing that residents’ personal and health care support needs and their personal wishes are recorded and met. EVIDENCE: Residents’ files contained information on their personal care needs and what they are able to do for themselves and their preferences in how the staff should support them with their personal care. The Medication Administration Record (MAR) sheets of most of the residents were viewed and show that staff have been correctly recording the administration of medication. The training files of five staff were viewed and showed that they have received appropriate medication administration training. The staff team have produced a comprehensive record for residents’ health and funeral arrangements. It contains information on whether the resident would like to stay in the home if they become terminally ill, the names of people they would like to visit them. There is also substantial information regarding their funeral arrangements, including readings, songs/hymns and prayers. There were also pictorial aids for residents with communication difficulties. One resident’s file contained a cassette compiled by his family for music that he would like played at his funeral. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 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 the following standard(s): 22. Staff are ensuring that complaints are taken seriously and the appropriate action is taken. EVIDENCE: The home has a comprehensive complaints policy and procedure. The last complaint recorded was on 23rd November 2005. Records show that staff have been recording complaints and ensuring that thorough investigations occur and action is taken. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 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 the following standard(s): 24, 25, 26, 29 and 30. Staff are ensuring that residents live in a safe, clean and comfortable home that meets their individual and collective needs. However, residents are not being provided with all of the required specialist equipment to meet their personal needs. EVIDENCE: None of the doors in the home were propped open, as per a requirement at the previous inspection. The registered manager stated that work is soon to be carried out to fit magnetic self closing devices to most doors. All bedrooms have been decorated and furnished to suit the individual taste of the residents. The pictures of a resident’s favourite football team and individual players adorned his bedroom walls. The resident was spoken to briefly about football and the pictures on his bedroom walls, he said, “They are my favourite team”. On the day of the inspection, workmen were changing the flooring in one resident’s bedroom. The registered manager stated that this was as a direct result of assessing the resident’s needs and identifying that his independent access to his bedroom was restricted due to the hallway flooring not being aligned with his bedroom flooring. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 16 The home has two bathrooms and two toilets. However, the bath in one of the bathrooms does not allow some residents access due to its design and some of the residents’ physical disabilities. The registered manager stated that some residents are prevented from having a regular bath because of this. A requirement is made that an assessment is carried out to ensure that all baths are appropriate to meet the personal care needs of all residents. All areas of the home were found to be clean, tidy and free from any offensive odours. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 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 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, 35 and 36. The home is ensuring that robust recruitment and training procedures are followed and that all staff have a good understanding of their duties and are supported. EVIDENCE: Three staff were spoken to in private and all have a good understanding of their roles and responsibilities and the individual and collective needs of the residents. At the previous inspection, a member of staff only had one reference. On looking through the staff’s file, a second reference has been obtained. Other staff files viewed all contained the relevant information, including an application form, two references and Criminal Records Bureau (CRB) check. Five staff’s training file were viewed and all contained a copy of various mandatory training certificate such as food hygiene, health and safety and moving and handling. The supervision records of five staff were viewed and all have been receiving regular recorded supervision. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 18 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, 42 and 43. The home is being managed well by a competent and dedicated staff team, who are ensuring the health and safety of residents are protected. Residents’ finances and the homes budget are accounted for and adequate records are kept. EVIDENCE: The registered manager stated that she has been a Registered Nurse Learning Difficulties (RNLD) for the past fifteen years. She also stated that she has a certificate in management studies, and an assessors award. The registered manager explained that the organisation has a quality audit team and the operations manager carries out yearly service reviews/audits. Questionnaires are sent out to residents, staff, family and representatives. On receiving then back, the information is collated into an action plan, which is developed between the operations manager and staff at the home. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 19 The most recent service review/audit was seen, the reviewing/audit identified areas for development such as the decorating, furnishing and review of care plans and administration issues. A number of safety certificates were viewed and all were up to date and in order. The last London Fire Emergency and Planning Authority (LFEPA) inspection was carried out on 8th October 2003 no contraventions were identified. Fire drills and tests are carried out regularly. At the previous inspection there was financial discrepancies in two resident’s petty cash and requirement was made. At this inspection, a random sample of three residents petty cash was checked with the registered manager and all balanced according to the petty cash recording booklets. In addition the home did not have any business and financial plan in place for the year. At this inspection, there was information regarding the budget for 06/07, regarding the expenditure for the year. Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 20 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 2 3 x X X Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 X X 2 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Matlock Close 4 Score 3 X 3 4 Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 3 DS0000010536.V271056.R01.S.doc Version 5.0 Page 21 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 YA1 Regulation 4(1c)(2) 5(1a) Requirement The registered persons must ensure that the statement of purpose and service user’s guide are revised and a copy of each forwarded to the Commission. The registered persons must ensure that residents’ personal goals are recorded in their care plans. The registered persons must ensure that residents are supported to access leisure activities at all times if requested. The registered persons must ensure that an assessment is carried out to ensure that all baths are appropriate to meet the personal care needs of all residents. Timescale for action 10/03/06 2. YA6 12 (3) 16(n) 16(m,n) 10/03/06 3. YA14 10/03/06 4. YA29 23 (2n) 10/03/06 Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 22 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 Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 23 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 Matlock Close 4 DS0000010536.V271056.R01.S.doc Version 5.0 Page 24 - 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!