Inspection on 19/09/05 for Petts Hill, 142

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Petts Hill, 142 14/10/08

Petts Hill, 142 16/10/06

Petts Hill, 142 18/01/06

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 19th September 2005 10:55 Petts Hill, 142 DS0000027761.V250881.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.V250881.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.V250881.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.V250881.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th October 2004 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.V250881.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an un-announced inspection. It was carried out between 10.55 am and 2.25 pm on Monday 19th September 2005. The Registered Proprietors, one staff member who had covered duty the previous night and two service users were present at the beginning of the inspection. The Inspector was advised that one service user was independently involved in activities within the local community. The Inspector spoke to two service users. A tour was undertaken of the house and garden. The home’s records and documents were examined and general observations were carried out. The Registered Proprietors were co-operative and provided appropriate assistance throughout the inspection. Overall, the home was organised and well maintained. The service users appeared content and the atmosphere within the house was calm. What the service does well: The home has been successful in providing a secure and supportive homely environment for the service users in which they are able to maintain their independence. The Inspector spoke separately to two service users. Both reported being happily settled at the home and were observed to move freely and comfortably around the house. The home has maintained a permanent staff group of many years and the service users were observed to relate in a friendly manner with the Registered Proprietors. The health and safety records were satisfactory and up-to-date and indicated that the safety and welfare of the service users were safeguarded at the home. The home was essentially well run and focused on meeting the needs of the service users. The environment was pleasant and homely. Petts Hill, 142 DS0000027761.V250881.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. Petts Hill, 142 DS0000027761.V250881.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.V250881.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): 1,2,3,4, and 5. The home’s policies and procedures in relation to the assessment and admission of prospective new service users are satisfactory. EVIDENCE: The home’s policy on admissions was in place. This indicated that the home, family members, social workers and medical professionals would be involved in the assessment process and in establishing the home’s capacity to meet specific interests and aspiration. Prospective new service users would be invited to visit the home prior to admission and would be initially placed on a month’s trial period. The personal files of the service users were examined and these contained signed copies of signed Contracts/Statement of Terms and Conditions. Petts Hill, 142 DS0000027761.V250881.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Service users participate in the drawing up of individual care plans and are supported in maintaining independent lifestyles. EVIDENCE: Service users’ participation was indicated on all care plans examined during the inspection. These were satisfactorily drawn up and contained separate assessments in relation to health and personal care and specific interests had been identified. Planned intervention for achieving set goals was put into place and appropriate risk assessments had been undertaken. All care plans and related risk assessments were signed by the service user and reviewed every six months. The Registered Proprietors confirmed that service users remained independent within the home and made personal decision in relation to preferred interests and lifestyles. This was confirmed by the service users and observed during the inspection. For example service users held front door keys, left the home unaccompanied and participated independently in various outdoor activities. Petts Hill, 142 DS0000027761.V250881.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): 11,12,13,14,15,16 and 17. Service users rights are respected at the home. They are able to exercise their independence and maintain family links. Varied and nutritional meals are provided. EVIDENCE: The service users lived independently within the home’s supportive environment. They handled their finances, held front door keys and go and come as they wish. Service users who spoke to the Inspector confirmed that they participated in various separate activities such as meals out, shopping trips, bus rides, visits to the pub, the local library and attended day centres. Indoor activities included board games, reading, listening to music, watching TV or listening to music. No organised shared activities occurred during the inspection. However, service users were observed being involved in separate activities such as reading and watching TV in their bedrooms, or leaving the home to participate in organised outdoor activities. Petts Hill, 142 DS0000027761.V250881.R01.S.doc Version 5.0 Page 11 The Inspector was advised that service users also carried out various tasks within the home such as laying the table, tidying their bedroom or assisting with food shopping. The records indicated that service users were able to make decisions regarding meals and shared activities during service users’ meetings that were held on a six weekly basis. The Registered Proprietors reported that the home had an open visiting policy and that personal friendships and family contact were encouraged and facilitated. It was indicated on the menu that varied and wholesome meals were provided at the home. The service users confirmed that they were able to prepare separate light meals and that snacks and drinks were readily available. One service user was observed being served a cooked mid-day meal and another chose to independently prepare a light lunch during the inspection. Petts Hill, 142 DS0000027761.V250881.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 and 20. The individual care needs of the service users are being met at the home. Service users are able administer their own medication where appropriate. However, medication kept at the home was not satisfactorily stored or documented and medication training had not been delivered to the care support staff. EVIDENCE: The Registered Proprietors reported that the service users at the home were self-caring but support in the form of prompting or supervision was delivered where appropriate. The health care needs of the service users were stated on care plans viewed at the time of the inspection and indicated that separate health care needs such as dental, optical and psychiatric care were being accessed. GP appointments were arranged as required. The home’s medication policy was in place. However, medication kept at the home was not satisfactorily stored. Documented sheets were not kept separately or filed in order. There were no signatures to confirm that the morning medication dosages had been administered on the day of the inspection. Petts Hill, 142 DS0000027761.V250881.R01.S.doc Version 5.0 Page 13 The Registered Proprietors confirmed that the care support staff had not received medication training but that appropriate advice would be sought from the pharmacist. The Inspector was informed that one service user controlled and administered his/her own medication. Petts Hill, 142 DS0000027761.V250881.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 and 23. The service users are essentially protected from abuse and they are able to express their views. However, cash that was safeguarded on behalf of a service user was not satisfactorily secured and related expenditure was not clearly recorded. EVIDENCE: The home’s policy and procedures on complaints were in place, clearly stated and accessible to the 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 at the home and the records indicated that training of Abuse had been delivered to the care support staff. The Inspector was advised that the home held responsibility for the finances of one service user. The Inspector examined the financial records of one service user. No discrepancy was identified but expenditure was not clearly recorded and cash was not satisfactorily secured. Petts Hill, 142 DS0000027761.V250881.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): 24,25,26,27,28 and 30. The home provides adequate space and facilities for meeting the separate, shared and personal needs of the service users. The overall environment is safe, pleasant and homely but the garden at the rear of the house required attention. EVIDENCE: The Inspector spoke to two service users both reported being comfortable and feeling safe and at home within the house. The service users’ bedrooms were viewed. All contained individual locks, were suitably fitted and reflected individual choices and interests. There is one bathroom and one separate toilet on the first floor. These facilities are adequate for meeting the private and personal needs of the service users. Service users were observed to freely access the kitchen and lounge/dining room during the inspection. Although the garden required attention, the house was essentially hygienically clean and well maintained. Petts Hill, 142 DS0000027761.V250881.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): 32,34,35 and 36. The care support staff members are supervised. They are competent and have received training for meeting the needs of the service users. Medication training has, however, not been delivered. EVIDENCE: Training Certificates viewed at the time of the inspection confirmed that one care support staff member was a Registered Mental Nurse and two care support staff members had obtained Levels 2 and 3 NVQ qualifications. Training on fire safety, abuse and health and safety had been delivered at the home. The Inspector was advised that medication training had not been delivered to the care support staff. Three personnel files were examined were found to contain all the required documents. Five permanent care support staff members including the Registered Proprietors were employed at the home. The rota indicated that one staff member was on duty during the day shifts and there was one sleep-in cover at night. Petts Hill, 142 DS0000027761.V250881.R01.S.doc Version 5.0 Page 17 The Registered Proprietors were observed to respond appropriately to the needs of the service users during the inspection. Service users who spoke to the Inspector expressed satisfaction with the standard of care they received at the home. Supervision records were inspected and suggested that the care support staff received appropriate supervision at least six times each year. Petts Hill, 142 DS0000027761.V250881.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 and 42. The home provides an appropriate environment for meeting the specific needs of the service users and their safety and welfare are safeguarded. EVIDENCE: The home provides supervision and support to the service users within an environment where they are able to be independent and maintain individual lifestyles. The records indicated that service users were able to express their views during service users meetings that were held every six weeks, and also during twice yearly reviews. The Inspector spoke to two service users. They confirmed their views in relation to preferred meals, allocated chores, shopping and individual support were being heard and acted upon at the home. The home’s policy on health and safety was in place. Petts Hill, 142 DS0000027761.V250881.R01.S.doc Version 5.0 Page 19 Health and safety maintenance checks were seen to be satisfactory and up to date. These included tests in relation to fire safety/drills, portable appliances, emergency lighting, the gas boiler and electricity installation. Appropriate environmental risk assessments had been undertaken. Petts Hill, 142 DS0000027761.V250881.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 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Petts Hill, 142 Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000027761.V250881.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO 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 Timescale for action 30/10/05 2 YA23 17(3) (a) 3 YA30 23(2) (O) 4 YA36 18(c) (1) The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person must 30/10/05 ensure that service users’ financial records are kept up to date. The Registered Person must 30/11/05 ensure that external grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained. The Registered Person must 30/12/05 ensure that persons employed to work at the care home receive training appropriate to the work they are to perform. Petts Hill, 142 DS0000027761.V250881.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.V250881.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. Extracts may not be used or reproduced without the express permission of CSCI Petts Hill, 142 DS0000027761.V250881.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. 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