Inspection on 07/07/05 for Positive Community Care

This inspection was carried out on 7th July 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 but made no statutory requirements on the home.

Other inspections for this house

Positive Community Care 09/01/07

Positive Community Care 23/05/06

Positive Community Care 13/12/05

Positive Community Care 30/09/04

Positive Community Care 11/05/04

Positive Community Care 01/12/03

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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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 7th and 15th July 2005 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 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 Stationary 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Positive Community Care Address 174 Petts Hill, Northolt, Middlesex UB5 4NW Telephone number Fax number Email 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 248 8496 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th September 2004 Brief Description of the Service: Positive Community Care 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 as part of a rehabilitation process, where applicable. Levels of support are defined through individual assessments of need. Positive Community Care was established in September 1997 and later extended when two former semi-detached houses were joined by the creation of an interconnecting door. The bedrooms are all registered as single rooms but contain double beds. One bedroom is en-suite with a toilet, shower and washhand basin. The home has adequate communal rooms, conservatory and large rear garden. A semi-independent unit has more recently been established in the next door property. The establishment is in a residential area, on a bus route and convenient to shops and other amenities. Positive Community Care Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that started at 9.50 am on the 7th July 2005. The Inspector met the support worker on duty and was later joined by the Registered Manager who is also the joint proprietor. He spoke to all the service users who were present, and examined the files and records. The home had no vacancies and was fully staffed (except that a fulltime rather than a part-time manager is employed). The Inspector inspected the home against 37 of the National Minimum Standards for care homes for younger adults and found that 23 were fully met, 5 were almost met, and 9 were not met. The Inspector made 24 requirements, 5 of which were re-stated from the last inspection report as they had not been acted upon by the home’s management. A second inspection visit was made at 1pm on July 15th 2005. This was check on compliance with certain requirements made verbally on the first visit. In agreement with the Registered Provider, three ‘immediate requirements’ were made concerning fire precautions, storage of medication, and staff Criminal Record Bureau disclosures. What the service does well: What has improved since the last inspection? The home has been decorated throughout, and the kitchen has been refurbished. Most of the requirements made at the time of the last inspection have been acted upon. Additional members of staff have gained National Vocational Qualifications, and weekly quality audits of the home’s procedures are now undertaken by the management. The value of these internal audits is however questioned as important Health and Safety issues are not being picked up on which could have serious implications for service users. Positive Community Care Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Positive Community Care Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Positive Community Care Version 1.10 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 standard(s) 1,2,3,4,and 5 Outcomes for Standards 1 to 4 were fully met. The Outcome for Standard 5 was almost met. EVIDENCE: The Statement of Purpose and Service Users’ Guide were examined and found to be well produced. A statement of Terms and Conditions has been issued to the newer service users, but not to the original service users of the home, as required. New service users are assessed in advanced of their moving in, appropriate trial visits are set up, and a review is held 4 weeks after moving in. All current service users are subject to the Care Programme Approach (CPA). Positive Community Care Version 1.10 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 standard(s) 6, 7, 8 and 9 The outcome of all the above Standards was fully met. EVIDENCE: The Inspector undertook case-tracking using the care records of two service users. Appropriate records were being kept, including service user plans, CPA care plans, formal six monthly reviews and internal monthly reviews, all of which had been agreed and signed by the service users. Risk profiles and risk assessments that supported an independent responsible risk taking attitude were also present on the files. A rota demonstrated the involvement of service users in looking after the home they lived in. Minutes were seen of a service users’ meeting. Positive Community Care Version 1.10 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 standard(s) 11, 12, 13, 14, 15, 16, and 17 All the outcomes for the above Standards were fully met. EVIDENCE: No services users work or attend college. However, three service users attend Manor Gate, (Ealing Council operated community resource centre), one attends Ealing Mencap evening sessions, one goes to Ealing Hospital’s gymnasium, and one attends work rehabilitation at Ealing Hospital. The home takes service users out for shopping trips, tea, and museum day trips. A fortnightly lay church meeting takes place in the home. Some relatives visit the home, some service users go home for weekends, one service user has a partner who stays overnight. The menu examined demonstrated that choices were on offer. Positive Community Care Version 1.10 Page 11 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 standard(s) 18, 19, 20, and 21. Outcomes for Standards 19, and 21 are fully met. The outcome for Standard 18 is almost met. The outcome for Standard 20 is not met. EVIDENCE: Care plans demonstrated that personal support, physical and emotional health needs had all been assessed and were on the face of it generally being met. However one service user was seen to be using a very dirty bib. He should have a clean bib for every meal. Privacy was maintained in terms of bedrooms being lockable. There is flexibility in the home concerning when to get up in the morning, for example. All service users are supported by the Community Mental Health Team, three service users have a Community Psychiatric Nurse allocated to them, there is a choice of GP possible, and a psychologist and psychiatrist are available as required. None of the service users are selfmedicating. The home has a policy to cover aging and death. The key-worker system is used. The Inspector examined the medication storage facility, the records of administration of medication, and the records for medication returned to Boots the Chemist. In addition, storage of medication remained untidy. There were a large number of errors in the current week’s record of medication administered. Code letters E, F and C were all used to explain the same situation where a service user had been admitted to hospital. Medication was Positive Community Care Version 1.10 Page 12 being administered when the MAR sheet said ‘none supplied this month’. This was because a hospital or GP had prescribed medication that was not supplied by Boots, but no additional prescription entry had been put onto the MAR sheet. Where such additional entries had been made, they did not show at what time of day the medication should be given. In one case medication prescribed to be given at 6pm had been given at 8am. Another service user did not have his 8am medication at all according to the record. Despite requirements made in the last pharmacy inspection, a representative of the home was not signing the medication returned to Boots record. Although the Boots pharmacist also signed for receipt but had not done so either in April 2005. The inner storage cupboard of the medicines cabinet had not been secured, again despite this being a requirement of the Pharmacy Inspection, November 2004. All these omissions must be rectified swiftly and staff trained in the detail and importance of accurate medication administration recording. Positive Community Care Version 1.10 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 standard(s) 22 AND 23 The outcomes for Standard 22 were not met. The outcome for Standard 23 was almost met. EVIDENCE: A complaints policy leaflet hangs in the hall of the home. This policy and the home’s procedure require some amendments since they do not refer to ‘Positive Community Care’ or 174 Petts Hill. In addition, the leaflet does not state that the complaints policy relates to a registered care home, neither does it mention any timescale for investigating complaints, nor say that complaints can be made directly to the CSCI at any time. One complaint in the complaints file was in the form of a grievance by a member of staff against another staff member. It must be re-filed under ‘grievances’ and kept securely with other confidential staff records. A copy of Ealing Council’s Adult Protection procedure was seen. Staff must be trained in its application. Positive Community Care Version 1.10 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 standard(s) 24, 25, 27, 28, and 30. Outcomes for Standards 25, 28 and 30 were fully met. The outcomes for Standard 27 were almost met but the outcome for Standard 24 was not met. EVIDENCE: The care home was seen to be homely enough but cannot be considered to be wholly safe for service users. There is a backlog of maintenance items that could affect safety. The patio doors leading into the back garden do not shut securely, thus intruders could easily gain access. A bath is missing the handrail that is designed for users to hold when entering or leaving the bath. Only one out of four electric light bulbs in the conservatory was working. Dishwashing chemicals marked with the COSHH ‘X’ were not locked away. Important fire precaution work ‘strongly recommended’ by the London Fire Service had not been carried out (see Health and Safety section for details). The Inspector himself had to put out a preventable fire during the inspection when a tissue placed in an ashtray by a service user caught fire after a lit cigarette end fell on it. A different design of ash-tray would prevent this from happening. The fire-alarm did not go off during this incident, although it did go off for some unknown reason earlier on. Thus the smoke alarm in the conservatory and the whole fire alarm system must be checked by a fire prevention expert. Positive Community Care Version 1.10 Page 15 It was noted that only one bedroom has a wash-hand basin installed. One bathroom contained a filing cabinet that served as the cleaning chemicals store. More suitable storage arrangements are required. The whole building and garden were inspected including two service users’ bedrooms, with their permission. Furnishings in bedrooms and communal areas were adequate. Space requirements are met. Sufficient toilets, bathrooms and showers are present. The home was sufficiently clean and tidy. Service Users’ privacy was being maintained. Positive Community Care Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, and 35. Outcomes for Standards 31, 32, and 33 were fully met. The outcomes for Standards 34 were almost met. The outcome for Standard 35 was not met. EVIDENCE: A job description and person specification for a support worker was seen and approved. A staff rota was seen. The staff to service user ratio is 1 to 7, including at night. The registered manager is supernumerary but only works part time. At other times, her brother and joint proprietor is present and he looks after the books and accounts. The number of NVQ qualified staff meets the requirement. Induction of new staff does take place but the records are not wholly adequate. References are taken on new staff but on the three staff files examined, old CRB certificates were used, that is ones that had been undertaken by the previous employer. It is a requirement that Positive Community Care must take up a new CRB disclosure enquiry through their appointed umbrella body whenever a new employee is taken on. This must be done retrospectively. Employees must not start work until at least the ‘POVA first’ check has been received back ‘as clear’. Positive Community Care Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39, 41, 42 and 43 The outcomes for Standards 37, 39, 41, 42, and 43 are not met. EVIDENCE: On the basis of evidence concerning lack of maintenance, health and safety, (especially fire danger issues), and medication error issues, it cannot be said that ‘service users benefit from a well run home’ (Outcome 37). A major component here is that the Registered Manager is only rota-ed to work 20 hours per week, that is 9am to 2 pm, four days a week. On the day of the inspection the Registered Manager did not arrive until 10.30am. On other days her business partner is in the home, but he has neither a management nor a care provider role. He is outside of the management/staff hierarchy and has no job title, hence lines of accountability when the Registered Manager is not onsite are unclear. The Registered provider must therefore review the management arrangements of the home. A second problem is with Quality Assurance. Although service users have been surveyed by questionnaire, that has not led to the required ‘annual development plan’. The Registered Provider Positive Community Care Version 1.10 Page 18 reported that internal audits do now take place, but regrettably these have not picked up the maintenance, health and safety and medication shortcomings detailed above. There is clearly a lack of management within the home, which must be urgently addressed. The potentially most serious implication is that the London Fire and Emergency Planning Authority’s Fire Inspection report dated 1st July 2004 has not been actioned. The report states,” This authority would recommend fitting electro-magnetic door holders. The cupboards under the stairs are used to house washing machines and tumble driers although the underside of the staircase and the doors to the cupboards are not of a fire resisting structure. It was noted that these cupboards have smoke detection but you must be aware that if a fire were to start in these areas, by the time the detectors actuate, the fire may already be affecting the staircase trapping persons on the first floor. This authority STRONGLY RECOMMENDS (AS IT DID IN THE LETTER TO YOU DATED 16TH JANUARY 2003) making the cupboards under the stairs 30 minutes fire resisting.” The Registered Manager reported to the Inspector that this work had been done, but an examination by the Inspector disclosed that this was not the case. Record keeping was not good as the medication records show. Service users cannot be confident that their views underpin developments within the home as no action plan based on their surveyed views exists. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 Positive Community Care Score Standard No Version 1.10 Score Page 19 1 2 3 4 5 3 3 3 3 2 22 23 ENVIRONMENT 1 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 x 2 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 3 Standard No 37 38 39 40 41 42 43 Score 1 x 1 x 1 1 1 Positive Community Care Version 1.10 Page 20 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 5 Regulation 5 (b and c) 13 (2) Requirement Each service user must be issued with an individual statement of the terms and conditions in respect of their accommodation. When medication is received into the home midcycle, the MAR must be amended to show the name of the medication, the quantity, the strength, the time to be administed, and the member of staff must sign the entry.THIS IS PARTLY RESTATED FROM THE LAST PHARMACY INSPECTION. THE IMMEDIATE TIMESCALE FOR ACTION WAS NOT MET. Ensure that all medication administered is correctly documented on the MAR sheets, with the correct endorsements. THIS IS RESTATED FROM THE LAST PHARMACY INSPECTION. THE IMMEDIATE TIMESCALE FOR ACTION WAS NOT MET. Ensure that when medication is returned to the pharmacist for disposal, the etries are dated and signed by both the home and the pharmacist. THIS IS RESTATED FROM THE LAST PHARMACIST INSPECTION AND Version 1.10 Timescale for action 01/10/05 2. 20 01/08/05 3. 20 13 (2) 01/08/05 4. 20 13 (2) 010805 Positive Community Care Page 21 5. 20 13 (2) 6. 20 13 (2) 7. 20 and 39 13 (2) 8. 9. 22 22 THE IMMEDIATE TIMESCALE WAS NOT MET. The inner metal medication cupboard must be bolted to the outer cupboard for the additional security of any controlled drugs held in the home. THIS IS RESTATED FROM THE LAST PHARMACY INSPECTION AND THE TIMESCALE FOR ACTION OF 01/12/04 WAS NOT MET. All staff who administer medication must receive further training in the process and importance of correct recording. The managements internal auditing system must be strengthened so that it picks up errors in recording medication.THIS WAS A RECOMMENDATION AT THE LAST PHARMACY INSPECTION. The complaints policy and procedure must include the details stated in the text above 01/08/05 01/09/05 01/09/05 01/10/05 10. 11. 12. 13. (transferre d to recommend ations) 23 18 (1c) and 13(6) 24 and 42 24, 27 and 42 24 and 42 23 (2) (p) 23 (2) (n) 23 (4c) 14. 24 and 42 23 (4a) 15. 24 and 42 23 4(b) The homes staff must be trained in applying Ealing Councils Adult Protection procedure. Replace the missing light fitting in the conservatory and the broken bulbs Replace the missing bath handrail Have a fire prevention expert check the smoke detector in the conservatory and the fire alarm system generally. Replace the ashtray in the conservatory with one that cannot accommodate waste paper. Fit elecrto-magnetic door closers and line the cupboards under the stairs, and their doors, to make Version 1.10 01/10/05 01/09/05 01/09/05 01/08/05 01/08/05 01/08/05 Positive Community Care Page 22 them 30 minute fire resisting. 16. 17. 18. 19. 20. 21. 22. 23. 24. 24 and 42 24 24 and 42 18 34 35 37 39 39 23. (2)(b) 23 (2) (l) 13 (4) 12 (4) (a) 19 18 (1c) 18 (1a) 24 24 The patio doors must be adjusted so that they are again lockable. The filing cabinet used as a cleaner store in one bathroom should be removed or replaced. All COSHH chemicals must be kept securely. Clean bibs must be available for use at every meal time, as required. A new CRB disclosure must be obtained for each new employee The system for recording induction training undertaken must be improved. The Registered Proprietor must review the management arrangements An annual development plan reflecting aims and outcomes for service users, is required. The providers internal audit system must be improved 01/08/05 01/10/05 01/08/05 01/08/05 01/08/05 01/10/05 01/09/05 01/10/05 01/09/05 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. Refer to Standard 22 and 41 Good Practice Recommendations Complaints that are staff grievances should be filed as such and kept securely for reasons of confidentiality. Positive Community Care Version 1.10 Page 23 Commission for Social Care Inspection Ground Floor 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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