Inspection on 15/12/05 for Person Centred Care Homes

This inspection was carried out on 15th 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Person Centred Care Homes 21/07/05

Person Centred Care Homes 12/11/04

Person Centred Care Homes 29/06/04

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 Person Centred Care Homes 1 Bodiam Close Enfield Middlesex EN1 3HZ Lead Inspector Anthony Lewis Unannounced Inspection 09:00 15 and 21 December 2005 th st Person Centred Care Homes DS0000030409.V269424.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 Person Centred Care Homes DS0000030409.V269424.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. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Person Centred Care Homes Address 1 Bodiam Close Enfield Middlesex EN1 3HZ 020 8366 7557 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) Mr Savvas Michael Mrs Maria Newton Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disabilities Restriction That the home may not be used by people with physical disabilities. This is in accordance with Regulation 16 of The Care Home Regulations 2001 and the National Minimum Standards for Care Homes for Younger Adults - Standard 25.4. Manager Qualification That the Registered Manager attains NVQ level 4 in Management and Care by 2005. This is in accordance with Regulation 9 of The Care Home Regulations 2001 and the National Minimum Standards for Care Homes for Younger Adults - Standard37.2 (ii). 21st July 2005 2. Date of last inspection Brief Description of the Service: Person Centred Care Home is a care home registered to provide residential services to four adults with learning disabilities. The home is located in a quiet residential area close to the shopping and transport facilities of Enfield Town Centre. The provider, Mr Savvas Michael, has another home near Enfield Town Centre. The home has two floors. The bedrooms, staff sleeping room, bathroom and toilet are situated on the first floor. The ground floor comprises of the kitchen, dining area, lounge, activities room, office and laundry room. There is a spacious garden both at the front and the rear of the house. The home specialises in providing support for service users who are on the autistic spectrum and who may have complex behavioural needs. The philosophy of the home is to support service users to achieve individual lifestyles, enhance peoples daily experiences and improve social inclusion. Person Centred Care Homes DS0000030409.V269424.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 15th December 2005 at 1.15pm and was completed at 4.40pm. The registered manager was away on annual leave for a few days. The registered provider and the deputy manager were available throughout the inspection and were very helpful and accommodating. To provide evidence for this inspection, one resident was briefly spoken to informally and three staff were spoken to formally. Various residents and staff files were viewed along with various other documents, and safety certificates. Two heath and social care professionals comment cards were received, one from a community nurse and one from a GP. One requirement was made at the previous inspection, which was met. One requirement was also made at this inspection. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. All of the core standards have been inspected over the two inspections for the year. The home is well run and organized by a dedicated registered provider, registered manager and support staff, who have the skills and knowledge to meet the needs and challenging needs of residents. The staff have gone to great lengths to ensure that aids are available to assist with communication between the residents and staff team. The staff are committed to ensuring that residents receive a good quality of care and that they live in a homely and comfortable environment. From discussions with staff, it would appear that the registered provider and registered manager are always available to support and advise the staff when needed. What the service does well: The registered manager has a comprehensive filing system with documents and other information arranged in a manner to ensure easy access is available. Residents are cared for by an adequately trained staff team who have a good understanding of individual residents’ needs. The home has been provided with equipment to meet the needs of residents with mobility difficulties. The home is comfortable, clean and well presented. The staff team have ensured that the residents’ needs are the focus of their attention throughout the day. Throughout the home, especially in the kitchen, lounge and activities rooms Makaton symbols and pictures are used as an additional method of residents and staff communicating with each other. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Person Centred Care Homes DS0000030409.V269424.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 Person Centred Care Homes DS0000030409.V269424.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. Prospective residents to the home have clear information to enable them to make an informed choice as to whether the home can meet their individual needs. EVIDENCE: The statement of purpose and service users guide were viewed and contained comprehensive information on the aims and objectives of the home and the facilities and services that the home provides. Person Centred Care Homes DS0000030409.V269424.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. Proactive communication aids enable residents and staff to communicate with each other, ensuring that residents are able to make their wishes and choices known to staff. Policies and procedures regarding confidentiality are being followed and is being stored securely. EVIDENCE: Throughout the home there are Makaton symbols and pictures to enable residents with communication difficulties to communicate their choices and wishes to the staff team and for the staff to communicate with residents regarding issues within the home. A resident was observed entering the activities room with a member of staff to indicate to the member of staff what the resident wanted. Personal information about residents such as their care plans, risk assessments and personal details are kept in lockable cupboards in the office. The home also has an adequate policy and procedure on confidentiality. Person Centred Care Homes DS0000030409.V269424.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, 14 and 16. The staff’s commitment to a person centred approach ensures that all residents are integrated within their community and their rights to everyday living experiences are upheld. EVIDENCE: The deputy manager stated that none of the residents participate in religious ceremonies, but could do if they so wished. Residents care plans revealed that they all participate in age appropriate leisure activities such as going to the pub, shopping and going for walks. The activities room contained a range of pictures and symbols of activities, which according to the deputy manager, are used by residents and staff to communicate to each other. One resident’s care plan contained information on the activities that he enjoys. Residents were observed moving about the home freely and with staff support where necessary. One resident was observed entering the activities room with a member of staff and pointing to a Makaton symbol to communicate his wishes before leaving with the member of staff. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 11 Residents were observed moving about the home freely and with staff support when necessary. Staff were observed knocking on residents’ bedroom doors before entering. Interaction between resident and staff was respectful and genuine. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 12 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 and 20. Staff intervention ensures that residents are appropriately supported with their personal and health needs where necessary. EVIDENCE: Residents’ care plans contained information on what support they require with their personal care, such as moving and handling, reminding residents to bathe and buying personal care products. The deputy manager stated that some resident need reminding in relation to their personal care, but that they do a lot of their own personal care with little support from staff. The deputy manager stated that none of the residents administer their own medication. The Medication Administration Record (MAR) sheets for all of the residents were viewed, along with their medication. Staff are correctly administering and recording residents’ medication. Two health care professionals comment cards indicated that residents’ medication is appropriately managed. Person Centred Care Homes DS0000030409.V269424.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): 22. The staff team are ensuring that Residents’ views are taken seriously by ensuring that robust policies and procedures are in place if residents wish to make a complaint. EVIDENCE: The home has a comprehensive complaints policy and procedure in place. When viewed, there were no complaints recorded since the previous inspection. The two comment cards received from health card professionals indicate that they have never received any complaints about the home. Person Centred Care Homes DS0000030409.V269424.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. A dedicated staff team and residents ensure that all areas of the home are kept clean, tidy and comfortable. EVIDENCE: A tour of the home was conducted with the registered provider. All areas were seen to be safe, homely and comfortable. Two residents were spoken to informally and both said that they enjoyed living in the home. One resident said that his bedroom is comfortable. All areas of the home were found to be clear and tidy. The home’s Control of Substances Hazardous to Health (COSHH) cupboard was seen to contain sufficient products for keeping the home hygienically clean. All (COSHH) products were locked away and the keys retained by the staff. One care worker spoken to said that staff and most residents help to clean the house and keep it tidy. Person Centred Care Homes DS0000030409.V269424.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): 32, 33 and 36. The residents are supported by a dedicated, competent and sufficiently trained and proactive staff team who are in addition supported by a dedicated management team. EVIDENCE: The personal files of six staff were viewed and each contained a variety of training certificates appropriate to their work. The deputy manager stated that three staff are at present undertaking their National Vocational Qualification (NVQ) level 2 and two staff are undertaking their (NVQ) level 4. The certificate of one member of staff who has completed their (NVQ) level 2 and another member of staff who has completed a City & Guilds level 3 in care were seen. The present rota was viewed. It showed that there are usually between two and three staff on duty on the early and late shifts and two staff on at night. Three members of staff were spoken to formally and each had a good understanding of their roles and responsibilities. Pictures of the staff on duty each shift was seen on the activities room wall. Staff files viewed, each contained a copy of their supervision record and showed that all staff are receiving regular recorded supervision. The three staff Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 16 spoken to said that they felt supported by the registered manager, deputy manager and provider and are able to approach them if they have any issues to discuss. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 17 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): 39 and 42. The home’s self-monitoring system ensures that residents, their family and representatives views are used to measure the success of the home’s aims and objectives. Residents, staff and visitors are being put at risk due to insufficient monitoring of safety procedures. EVIDENCE: The registered manager said that she sends out quality assurance questionnaires to service users family and representatives and on their return will act on any comments or concerns and use the results from the questionnaire to improve the care to residents. Two completed questionnaire were viewed and contained a range of questions about the service provided to the residents. Various safety certificates and files were viewed. For instance, the fire awareness file was viewed and showed that fire tests and drills are carried out regularly. On looking at the London Fire and Emergency Planning Authority Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 18 (LFEPA) certificate dated 13th May 2005, there were three contraventions identified. On a tour of the home, all three contraventions had been complied with. However, a new certificate was not obtained. On request of the Portable Appliances Test (PAT) certificate, the registered provider said that the home did not have one. A requirement is made that the registered persons must ensure that a new (LFEPA) certificate is obtained to show that the identified contravention have been met and that a Portable Appliances Test is carried out and confirmation of this is forwarded to the Commission. Person Centred Care Homes DS0000030409.V269424.R01.S.doc Version 5.0 Page 19 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 X X X x Standard No 22 23 Score 3 x 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 3 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Person Centred Care Homes Score 3 X 3 x Standard No 37 38 39 40 41 42 43 Score X X 3 X X 2 x DS0000030409.V269424.R01.S.doc Version 5.0 Page 20 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 YA42 Regulation Requirement Timescale for action 24/02/06 23 (1a) The registered persons must (2c)(4c)(i) ensure that a further (LFEPA) certificate is obtained to show that the identified contravention has been met and that a Portable Appliances Test is carried out and confirmation of this is forwarded to the Commission. 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 Person Centred Care Homes DS0000030409.V269424.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 Person Centred Care Homes DS0000030409.V269424.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. 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