Inspection on 18/01/06 for Petts Hill, 142

This inspection was carried out on 18th January 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Petts Hill, 142 14/10/08

Petts Hill, 142 16/10/06

Petts Hill, 142 19/09/05

Petts Hill, 142 19/10/04

Petts Hill, 142 08/07/04

Petts Hill, 142 09/10/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Petts Hill, 142 Northolt Middlesex UB5 4NW Lead Inspector Ms Jean Bovell Unannounced Inspection 11:30 18 January 2006 th Petts Hill, 142 DS0000027761.V271802.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 Petts Hill, 142 DS0000027761.V271802.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. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Petts Hill, 142 Address Northolt Middlesex UB5 4NW 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) 0208 422 9910 00000000 Mr Lakshamanah Naicker Mrs Mala Devi Naicker Mrs Mala Devi Naicker Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th September 2005 Brief Description of the Service: 142 Petts Hill is situated on a residential road on the borders of Northolt and South Harrow. The home is registered for three people under the age of sixtyfive years with mental health care needs. There are currently three male service users at the home. The home is privately owned. The Registered Proprietors are Mr and Mrs Naicker and Mrs Naicker is the Registered Manager. The home is a semi-detached house. The ground floor has a small kitchen, a lounge/dining area and one service user’s bedroom. Two service users’ bedrooms, a bathroom and separate toilet, and an office are situated on the first floor. There is a garden at the rear of the house. There are five care support members of staff at the home. This includes the two Proprietors. One member of staff is on duty during the day and there is one sleep-in cover at night. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11.30 am and 3.40 pm on 18th January 2006. The Registered Proprietors one on whom is also the Registered Manager and three service users were present. The Inspector spoke to two service users. The home’s records, policies and procedures were inspected. A tour of the building was undertaken and observations were made. The outstanding Standards of the last inspection and the requirements made were examined at this inspection. The Proprietors/Registered Manager were co-operative and provided appropriate assistance throughout the inspection. What the service does well: What has improved since the last inspection? Of the eight requirements made at the last inspection, five had been complied with. These related to medication records, financial records and medication training. Petts Hill, 142 DS0000027761.V271802.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. Petts Hill, 142 DS0000027761.V271802.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 Petts Hill, 142 DS0000027761.V271802.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): Standard 1, 2, 3, 4 and 5 were examined at the last inspection and the minimum requirements had been satisfactorily met. EVIDENCE: Petts Hill, 142 DS0000027761.V271802.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. Service users privacy and confidentiality are respected and they are able to participate in decisions relating to all aspects of life at the home. Standards 6, 7 and 9 were examined at the last inspection and the minimum requirements had been satisfactorily met. EVIDENCE: It was evidenced on recorded minutes that service users meetings were held on a monthly basis and that topics such as activities and meals were discussed. Service users were also encouraged to express their opinion regarding staffing and the level of support they received at the home. The home’s policy and procedures relating to confidentiality were in place and accessible to service users and their relatives. The Registered Proprietors confirmed that confidential matters relating to service users were respected at the home and that they were able to make private telephone calls and receive personal mail. Service users also held front door keys and individual locks had been fitted onto bedroom doors. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 10 The service users records were viewed and found to be accurate, up to date and securely filed. Petts Hill, 142 DS0000027761.V271802.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): Standards 11, 12, 13, 14, 15, 16 and 17 were examined at the last inspection and the minimum requirements had been satisfactorily met. EVIDENCE: Petts Hill, 142 DS0000027761.V271802.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, 19, 20 and 21. Service users’ personal and health care needs are being appropriately met and the home’s policy on ageing, illness and death is satisfactory. Service users are able to administer their own medication but two requirements made at the last inspection under Standard 20 remain outstanding. EVIDENCE: It was indicated on individual care plans that the service users at the home received supervision, monitoring or assistance with their personal care. The Registered Proprietors confirmed that personal care routines were undertaken in privacy within the bathroom or individual bedrooms. Service users were able to choose times for getting up/going to bed and what they wore. The separate physical and psychiatric health care needs of the service users were being met and reflected care plans on viewed. There were annual dental and eye tests, regular visits from the community psychiatric nurse and planned psychiatric reviews. GP appointments were arranged as required. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 13 Medication at the home was safely stored and satisfactorily administered and signed. One service user was self administering his medication at the time of the inspection. All current medicines had been recorded and complied with a requirement made under Standard 20 at the last inspection. The Inspector was informed by the Registered Proprietors that training on medication would be delivered by the pharmacist to all members of the care support staff on 20/01/06. This was in compliance with a requirement made under Standard 20 at the last inspection. The requirements made at the last inspection, under Standard 20, that the home’s medication policy must be updated and that full instructions correlating with labels must be stated on MAR sheets, remained outstanding. The home’s policy on ageing, illness and death was in place and individual wishes or requests were appropriately recorded. Petts Hill, 142 DS0000027761.V271802.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): 23. Standard 22 was examined at the last inspection and the minimum requirements had been met. The safety and welfare of the service users are being satisfactorily protected and a requirement made under Standard 23 at the last inspection had been met. EVIDENCE: The financial records relating to one service were examined and found to be accurate, up to date and appropriately secured. This complied with a requirement made under Standard 23 at the last inspection. The home complaints procedure was clearly and appropriately stated and accessible to service users and their relatives. No complaints had been made to the home since the last inspection. The London Borough of Ealing guidelines on the Protection of Vulnerable Adults was in place and the records indicated that training on Abuse had been delivered to all members of the care support staff team. Petts Hill, 142 DS0000027761.V271802.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): 29 and 30. Specialist equipment is not currently required at the home. A requirement made under Standard 30 at the last inspection remains outstanding. Standards 24, 25, 26, 27 and 28 were examined at the last inspection and the minimum requirements had been satisfactorily met. EVIDENCE: The service users at the home are fully mobile and do not experience physical difficulties. Aids or adaptations are, as a consequence, not currently required. The home was cleaning and a complied with. been made for generally clean and hygienic. However, the carpets required requirement regarding the upkeep of the garden had not been The Registered Proprietors reported that arrangements had the garden to be cleared of discarded items of furniture. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 16 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, 33 and 36. Members of the care support staff team are aware of their specific role in supporting the service users. They are appropriately trained and are regularly supervised. Standards 32, 34 and 35 were examined at the last inspection and the minimum requirements had been satisfactorily met. EVIDENCE: The records indicated that members of the care support staff team received job descriptions and that they were aware of their specific role in supporting the service users. The Registered Providers confirmed that one new care support worker had been recruited to the home since the last inspection and had received induction/mandatory training. This was reflected on records viewed during the inspection. One care support worker was a qualified mental health nurse and two had obtained NVQ in levels 2 and 3. Training on adult abuse, fire safety, health and safety, food hygiene and moving and handling had been delivered to all members of the care support staff team. Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 17 The Inspector was informed by the Registered Providers that staff meetings were held each month and that annual appraisals were undertaken. It was evidenced on records viewed that staff supervision occurred at least six times each year. Petts Hill, 142 DS0000027761.V271802.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, 38, 40, 41 and 43. The Registered Manager is appropriately qualified and experienced and the home’s ethos is beneficial to the needs of the service users. The home’s policies and procedures are essentially satisfactory but require updating. The record keeping and management of the home ensures that the best interests of the service users are being safeguarded. EVIDENCE: The Registered Manager has had 26 years experience as a care worker and has occupied her present position for two years. She is currently receiving training for the Registered Managers Award. The Inspector was informed by the Registered Manager that the home’s ethos was based on promoting the independence of the service users, treating them Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 19 with respect and maintaining a comfortable and homely environment within the home. The service users’ records were viewed and found to be accurate, up to date and securely filed. The home’s policies and procedures were in place but had not been reviewed since 2003. The Employers Liability Insurance Certificate was up to date. The home’s business and financial figures dated April 2005 were satisfactory. Petts Hill, 142 DS0000027761.V271802.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 X X X X 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 X X X X X 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Petts Hill, 142 Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 X 3 DS0000027761.V271802.R01.S.doc Version 5.0 Page 21 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 YA20 Regulation 13(2) Requirement The home’s medicines policy must be updated to include procedures for the receipt, storage and disposal of medication. (This is re-stated from the last inspection. Previous timescale 1/05/05) The full instructions for administration should be stated on the MAR and these should correlate with labels on medicines. (This is re-stated from the last inspection. Previous timescale 01/11/05 The Registered Person must ensure that external grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained. (This is restated from the last inspection. Previous timescale 30/11/05) The Registered Person that carpets in the home are cleaned or replaced. The Registered must ensure that the home’s policies and procedures are reviewed. Timescale for action 30/04/06 2. YA20 13(2) 01/03/06 3. YA30 23(2) (O) 30/03/06 4. 5 YA30 YA40 23(2)(d) 17(3)(a) 30/03/06 30/06/06 Petts Hill, 142 DS0000027761.V271802.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 Petts Hill, 142 DS0000027761.V271802.R01.S.doc Version 5.0 Page 23 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. 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