Inspection on 13/12/05 for Positive Community Care

This inspection was carried out on 13th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Positive Community Care 09/01/07

Positive Community Care 23/05/06

Positive Community Care 07/07/05

Positive Community Care 30/09/04

Positive Community Care 11/05/04

Positive Community Care 01/12/03

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 Positive Community Care 174 Petts Hill Northolt Middlesex UB5 4NW Lead Inspector Robert Bond Unannounced Inspection 13th December 2005 10:00 Positive Community Care DS0000027713.V261345.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 Positive Community Care DS0000027713.V261345.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. Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 174 Petts Hill Northolt Middlesex UB5 4NW 0208 621 1724 0208 248 8496 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) Ms Charmaine Watson Ms Charmaine Watson Care Home 7 Category(ies) of Learning disability (0), Mental disorder, registration, with number excluding learning disability or dementia (0) of places Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th July 2005 Brief Description of the Service: Positive Community Care (PCC) is a care home for seven adults with mental health needs and/or a learning disability. The overall aim of the service is to support service users in maintaining and developing their independence and integrating into the community as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. The home was established in 1997, was initially two small homes operating side by side, which were later combined into one. A third house (166 Petts Hill which is next to 170) is operated by PCC as a supported living scheme (SLS). There is a throughput from the Care Home to the SLS, residents of the later are supported by staff from the care home, and residents often visit the care home where their medication and money may be kept. The care home’s bedrooms are all singles but containing double beds. One bedroom is en-suite. Two additional bedrooms are currently being created within the loft space. The home has adequate communal areas including a conservatory and large rear garden in which a ‘rehabilitation activities centre’ is being built at present. The home is in a residential area, next to a convenience store/petrol station, and on a bus route. The home has its own small bus, but this in not used at present. Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year, but an announced additional visit had taken place in October 2005. The outcomes of that visit will be contained within this inspection report. A number of complaints had also been received by the CSCI during November 2005, these were investigated by PCC and the outcomes will also be included in this inspection report. The Inspector met the proprietor who is also the Registered Manager, the manager who is currently seeking to become the registered manager, two support workers, and two service users. He toured the home and examined various records and care files, paying particular attention to the care plans of three service users selected at random (case-tracking), and questioning the manager about the extent of activities provided or made available to the service users. There are no vacancies for service users at present, but two additional single rooms are soon to become available. Additional support staff members are being recruited at present. The Inspector assessed the home against 13 of the National Minimum Standards (NMS) for care homes for younger adults. He found that 3 standards were met, but 10 standards were only partly met. The Inspector made 11 requirements, 2 of which are carried forward from the last inspection having not been achieved within the timescales set. The Inspector also made 6 recommendations. What the service does well: A personalised individual service is provided to service users in a way that promotes their independence. Some service users benefit from rehabilitation to the extent that they are able to move next door into the supported living scheme there, which is also operated by PCC. The managers and staff communicate well with service users who feel able to come to them with their concerns knowing that they will where possible be assisted. The key worker system appears to operate well. The Statement of Purpose and the Service user’s Guide are well produced. The care plan format is quite good. The Inspector was impressed that building work in the loft space was progressing without the builders having any access to it through the house. Therefore service users were minimally inconvenienced by the work and not put at risk provided they do not go into the back garden which is being used as the builder’s storage area. Positive Community Care DS0000027713.V261345.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. Positive Community Care DS0000027713.V261345.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 Positive Community Care DS0000027713.V261345.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): 5 The outcome is fully met EVIDENCE: NMS5: At the additional visit the Inspector ascertained that all service users now have individual statements of the terms and conditions attaching to their residence. Positive Community Care DS0000027713.V261345.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 The outcome for NMS 6 is not fully met for the reasons stated below. EVIDENCE: NMS6: The Inspector examined (case-tracked) the care files of three service users in detail. All contained a standard care plan template that had been designed to be completed ‘in the first person singular’, in order words by the service user themselves. This approach is commended in so far as it encourages person centred planning. The problem is that two of the care plans examined had been completed ‘in the third person singular’, in other words the key-worker had completed the plan. That would be alright if the key-worker was doing it on behalf of the service user but the wording used suggested otherwise. The gist was that we will do such and such for you, rather than we will assist you to do it. See Recommendation 1. All the care plans had a designated space for the key-worker to sign the plan and for the service user to sign their agreement to it. Only one care plan had been signed by the service user. See Requirement 1. Positive Community Care DS0000027713.V261345.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): 12, 13, 14 The outcomes for these standards are not fully met for the reasons stated below. EVIDENCE: Since the last inspection, the Inspector had received three letters of complaint from neighbours, mostly concerning the alleged behaviour of service users whilst in the home or in the immediate neighbourhood. The Inspector had passed the complaints to the Registered Manager for investigation and had received two written responses from the management of the home. It was clear from the complaints that service users were not fully integrated into the local community, thus the outcome for NMS13 is not fully met. The Inspector however welcomes the approach that has been made by the management of the home to the neighbourhood Residents Association requesting dialogue, and the suggestion that service users join the Residents Association. See Recommendations 2 and 3. When examining the care plans, the Inspector paid special attention to the extent that service users engage in regular organised activities or attend day centres. He found that 4 out of 7 service users attend day centres but only two of them on a regular basis and then only once or twice a week. The manager Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 11 reported that the problem was a lack of motivation. Service users are expected to make their own way to day centres on public transport as this is an aspect of promoting their independence. The home does own a 10 seater bus, but it is not used at present. The management should further consider whether a domestic type vehicle should be obtained and used to sometimes take service users to day centres and other activities if they would not bother to attend by public transport. See Recommendation 3. It is noted that a small ‘rehabilitation centre’ for up to six service users at a time is being built in the back garden of the care home. The manager reported that additional support staff are being recruited by the home, and it is hoped to use social work students to assist in organising additional activities within the centre. The Inspector hopes that service users will be motivated to use the centre but not at the expense of disengaging from day centres and other activities in the community. The manager produced a chart showing activities undertaken on a daily basis by each service user. It should be updated. Recommendation 6. Positive Community Care DS0000027713.V261345.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 The outcomes for NMS18 and NMS20 are not fully met EVIDENCE: NMS18: The Inspector observed service users at lunch-time. The last inspection report identified that one service user was using a dirty bib. It appeared that the same bib is being used and it must be replaced. Requirement 2. The same service user was observed to be dressed in ill-fitting clothes, which must be replaced. Requirement 3. NMS20: The Inspector examined the homes medication administration records and found them to be in order. The previous inspection report required that the community pharmacist provide training for the home’s staff. This has not yet taken place due to the pharmacist being too busy. Requirement 4. Positive Community Care DS0000027713.V261345.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 and 23 The outcome for NMS22 is met, that of NMS23 partly met. EVIDENCE: NMS22: As reported above a series of complaints had been received by the Inspector but the complaints were appropriated investigated and responded to by the management of the home. Further action is planned by the management in order to address the concerns raised. NMS23: At the last inspection, the Inspector made a requirement that the home’s staff be trained in Ealing Council’s adult protection procedure. Staff have been trained in adult protection by Mulberry Hose but not yet by Ealing. This remains a requirement. See Requirement 5. Positive Community Care DS0000027713.V261345.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 The outcomes for both Standards are not fully met for the reasons stated below. EVIDENCE: NMS24: All the requirements from the last inspection concerning the premises have been met. However some new requirements have been identified as follows. In the non-smoking lounge, the skirting board must be painted, the large package removed, broken light bulb replaced, the picture hung on the wall, and the ramp made more attractive. These aspects will all help the home become more ‘bright, cheerful and homely’ as per NMS24.6. See Requirement 6. One aspect of the complaints concerned the appearance of the care home from the front. The Inspector noted that a brick garden gate pillar had been partly demolished, and there was in the garden a large number of full black refuse bags, and some loose rubbish probably blown in by the wind. The manager reported the front gardens were to be remodelled to create parking and the brick pillar would be repaired then. The Inspector suggested that rubbish bags should be kept in the back garden, and brought out front only on ‘bin-day’. See Recommendation 5, which is in line with NMS24.8 that requires that premises should be ‘in keeping with the local community’. Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 15 NMS30: Although the home is generally clean and hygienic, the Inspector was concerned by the following: the state of the downstairs bathroom/toilet where he found his feet sticking to the floor (Requirement 7); and dirty windows such as that on the stairs of number 270. (Requirement 8). Positive Community Care DS0000027713.V261345.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): 33 and 34 The outcome for NMS33 is met, that for NMS 34 is partly met. EVIDENCE: NMS33: The home now has a dedicated full-time manager who is in the process of applying to the CSCI to be approved as the Registered Manager. He reported that the home now also has a deputy manager, and that two additional full time and two part time support workers are in the process of being recruited. NMS34: The Inspector checked the recruitment files of two of the new workers. He found that references were in place but only one Criminal Records Bureau certificate. The manager reported that the home no longer gets sent a copy but he believed the employee has received a copy. In that case, the home must obtained and keep a photocopy of it. Requirement 9. Positive Community Care DS0000027713.V261345.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 outcomes for both Standards are partly met. EVIDENCE: NMS39: Now that the Proprietor is no longer the day to day manager, she must implement Regulation 26 visits to the home to officially monitor the work of the home, and send a copy of her monthly reports to the CSCI. Requirement 10. NMS42: Continued vigilance must be maintained in the home concerning health and safety matters. The Inspector was pleased to see that building work was being carried on without putting the service users at risk, unless they went into the garden, which is currently the builder’s storage area. The Inspector noted two potential trip hazards in the downstairs hallway of number 270, namely a loose metal flooring strip, and a frayed carpet. Requirement 11. Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 LIFESTYLES Standard No Score 11 x 12 2 13 2 14 2 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Positive Community Care Score 2 x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000027713.V261345.R01.S.doc Version 5.0 Page 19 yes 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 YA6 Regulation 15 Requirement Timescale for action 01/02/06 2 3 4 YA18 YA18 YA20 5 YA23 6 7 YA24 YA30 Care plans should be signed by service users in order to demonstrate that they have been consulted and agree the contents of the plan. 12 (4) (a) Service users’ dignity must be respected by the provision of suitable bibs where necessary. 12 (4) (a) Service users’ dignity must be respected by the provision of suitable clothing. 13 (2) All staff who administer medication must receive further training in the process and the importance of correct recording. THIS IS RESTATED FROM THE LAST INSPECTION. The timescale of 01/09/05 was not met. 18(1c),13(6) The home’s staff must be trained in applying Ealing Council’s Adult Protection Procedure. THIS IS RESTATED FROM THE LAST INSPECTION. The timescale of 01/10/05 was not met. 23 (2) (b) The decoration and ambience of the non-smoking lounge must be improved 23 (2) (d) The downstairs bathroom toilet DS0000027713.V261345.R01.S.doc 01/01/06 01/01/06 01/02/06 01/02/06 01/02/06 01/01/06 Page 20 Positive Community Care Version 5.0 8 9 10 YA30 YA34 YA39 23 (2) (d) 19 and SCH.2 26 11 YA42 13 (4) must be thoroughly cleaned and kept clean. All the windows in the care home must be kept clean The home must have a valid and up to date CRB disclosure certificate on each employee The registered provider must visit the care home and report in accordance with this regulation. The identified trip hazards must be made safe. 01/02/06 01/01/06 01/01/06 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA13 YA13 Good Practice Recommendations Consistency is recommended in the way care plans are completed so that service users are fully empowered. Further efforts should be made to achieve integration of the home and its service users into the local community. The management of the home must remain alert to what neighbours may perceive as threatening behaviour or antisocial behaviour by services users, whether in the home, its gardens, or in the street, and take appropriate action to avoid or minimise distress to all concerned. The management should review their policy on the provision of transport to day centres and other outside activities. Bin bags should be stored out of sight. An up to date activity plan for all the service users 4 5 6 YA13 YA24 YA14 Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 21 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 Positive Community Care DS0000027713.V261345.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!