Inspection on 16/12/05 for Real Life Options 90 Capel Gardens

This inspection was carried out on 16th 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Real Life Options 90 Capel... 05/07/07

Real Life Options 90 Capel... 17/08/05

Real Life Options 90 Capel... 22/02/05

Real Life Options 90 Capel... 25/09/04

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Edenvale

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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 90 Capel Gardens 90 Capel Gardens Pinner Middlesex HA5 5RD Lead Inspector Ms Sue Barker Unannounced Inspection 16th December 2005 09:40 90 Capel Gardens DS0000017523.V269512.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 90 Capel Gardens DS0000017523.V269512.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. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 90 Capel Gardens Address 90 Capel Gardens Pinner Middlesex HA5 5RD 020 8868 7149 020 8868 7149 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) Real Life Options Mr Pankaj Bhalla Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: 90 Capel Gardens is a registered care home providing personal care and accommodation for a maximum of 6 adults aged 18-65 who have learning disabilities. The registered provider is the Real Life Options, a national care organisation. The responsible individual is Mr David Wandless and the registered manager is Mr Pankaj Bhalla. The home is a detached two storey building in a quiet cul-de-sac in a residential area. It is in keeping with the surrounding neighbourhood. It is close to Pinner and North Harrow where shops, pubs and other community amenities can be found. There is a bus stop at the bottom of the street and the home has its own people carrier to transport service users to community facilities. The home was first registered in 1994. All bedrooms are single, and none have en-suite facilities. There is a bathroom on each floor and an additional toilet. There are separate lounge and dining areas and a well-maintained garden that can be accessed through the rear of the home. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Most residents left the care home before the Inspector arrived at 9.40am and one was asleep in bed. Residents were mostly due to arrive back to the care home at about 3.30pm from their day placement. There were 6 residents living in 90 Capel Gardens at the time of the unannounced inspection. The Inspector observed one resident moving around the first floor of the building in a manner of his own choosing. Staff on duty were observed to be busy carrying out domestic tasks in the care home. There was 4 support staff on duty. Staff kindly spoke with the Inspector and demonstrated extensive knowledge of residents’ current issues and their goals and aspirations. Staff spoke about how residents spend their time. Residents’ weekly activities are displayed pictorially in the care home. Most residents have contact with their families and staff facilitate this contact. The ‘Visitors’ book indicates that there are a range of visitors to the care home. Staff were arranging for one resident to see a relative over Christmas. The unannounced inspection ended at 1.55pm. The Inspector would wish to thank staff that facilitate the unannounced inspection process and made the Inspector most welcome. What the service does well: What has improved since the last inspection? What they could do better: A full record of medication administered to residents by staff must be maintained. A number of areas within the building require decorative attention. There is a recruitment policy in respect of the care home that aims to protect residents. The Inspector was unable to judge its application, as the records were not available for inspection at the time of the unannounced inspection. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 6 Residents’ views and contributions need to be included in the required annual review of the quality of care and support available in 90 Capel Gardens. The health and safety arrangements for 90 Capel Gardens mostly present as protecting residents, though requirements arose regarding the fire safety arrangements. 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. 90 Capel Gardens DS0000017523.V269512.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 90 Capel Gardens DS0000017523.V269512.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): EVIDENCE: These key standards were considered at the previous unannounced inspection. 90 Capel Gardens DS0000017523.V269512.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): EVIDENCE: These key standards were considered at the previous unannounced inspection. 90 Capel Gardens DS0000017523.V269512.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): EVIDENCE: These key standards were considered at the previous unannounced inspection. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 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 the following standard(s): 20 Residents are mostly protected by the care home’s policies for dealing with medicines, with only attention being required to the recording of medication administered to residents by staff. EVIDENCE: The Inspector viewed the medication recording and storage in 90 Capel Gardens. The contracted pharmacist supplies a weekly dossette box system of medication administration to the care home. Staff maintain a record of medication administered to residents. This was fully documented other than on one occasion. There was clear guidance for staff on the circumstances in which medication is to be administered to a resident on a PRN basis. The medication cupboard was locked. It was well organised though is quite small. It is located in a store cupboard. One member of staff advised the Inspector that they had recently done medication training. This forms one aspect of the care home’s staff training programme. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: These key standards were considered at the previous unannounced inspection. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 13 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 Residents live in an environment that is mostly well maintained and decorated, in addition to being clean, bright and homely. Residents live in a care home that presented as clean and hygienic. EVIDENCE: The communal areas of the building were inspected and previous requirements followed up. The living room had been decorated for the forthcoming Christmas celebrations. Staff were observed undertaking cleaning tasks throughout the building. The building was warm on what was a cold December morning. A new bathroom suite had been fitted on the first floor since the Inspector last visited 90 Capel Gardens. This presented as a positive improvement to the facilities in the care home. The building is indistinguishable from others in the vicinity. A number of requirements were noted that are identified below. The Inspector viewed the laundry and was updated on progress in establishing a laundry area in the care home’s garage. This work is not complete and will include the installation of a laundry vent within the care home. This included consultation with the Fire Safety Officer and Environmental Health Officer. The Commission for Social Care Inspection must be updated on progress in completing the work on the care home’s laundry. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 14 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): 34 There is a recruitment policy in respect of the care home that aims to protect residents. The Inspector was unable to judge its application. EVIDENCE: These key standards were considered at the previous unannounced inspection. The Inspector did not view any of the recruitment information regarding individual members of staff as it was locked away and the Registered Manager only had access. The Registered Manager was not working in the care home during the unannounced inspection. The Inspector was unable to judge if the range of required checks had been carried out in respect of staff employed in the care home. The Inspector gathered from staff on duty that there was one staff vacancy for a support worker that had been recruited too. There remains an outstanding requirement regarding Standard 24 The rota indicated that there was 11 staff employed in 90 Capel Gardens, including the Registered Manager. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 15 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 & 42 Residents’ views and contributions need to be included in the required annual review of the quality of care and support available in 90 Capel Gardens. The health and safety arrangements for 90 Capel Gardens mostly present as protecting residents. EVIDENCE: A representative of the Registered Provider visits the care home on a monthly basis as required and a copy of the report of the visit is forwarded to the Commission for Social Care Inspection office. These visits cover aspects of the service such as medication, complaints, staffing and records. The Inspector viewed a ‘Quality Assurance’ file. This contained a report of a visit made to the care home by representative of the Registered Provider on 18/10/05 and a ‘Family Satisfaction Survey Analysis’ for 03/04’. It is required that a review of quality of care and support available in the care home is carried out annually that includes consultation with residents and stakeholders. It is required that the results any review of quality of care and support available in the care home are published and made available to service users, stakeholders and the Commission for Social Care Inspection. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 16 The Inspector noted the recording of a number of incidents that had occurred in the care home that fell within the categories of those that require reporting to the Commission for Social Care Inspection and had not. Information about the range of significant incidents that require reporting to the Commission for Social Care Inspection was left in the care home for consideration. This is required. The Inspector noted that training was available to staff in respect of food hygiene, fire safety, first aid, food hygiene and infection control. There is guidance for staff in respect of the handling of chemicals and the Inspector noted that this health and safety issue had been discussed at a staff meeting. Hot water taps in the building ran warm to the touch when tested. There was a Fire Risk Assessment on file dated 11/1/05. The fire bells are tested mostly on a weekly basis with a record maintained of outcomes, though not consistently as required. Three fire drill/evacuation exercises had been held since 3/10/04. It must be ensured that these are held quarterly. The Fire Safety Officer had recently visited the care home with no issues arising. Ranges of risk assessments for the service were viewed. There was evidence of their discussion by staff. 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 17 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 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 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 2 x x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 90 Capel Gardens Score x x 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x DS0000017523.V269512.R01.S.doc Version 5.0 Page 18 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 YA20 Regulation 13 Requirement There must be a full record of medication administered to residents by staff. Arrange for communal areas of the building to be decorated, including the hallways, ground floor bathroom, kitchen, entrance hall, lounge and dining room. Reinstate the toilet seat in the ground toilet. Ensure that certain evidence of the staff recruitment process (e.g. references) is available for inspection in the care home. (Previous timescale of 31/10/05 not met) It is required that a review of quality of care and support available in the care home is carried out annually that includes consultation with residents and stakeholders. It is required that the DS0000017523.V269512.R01.S.doc Timescale for action 16/02/06 2 YA24 23 16/04/06 3 4 YA24 YA34 23 17 16/02/06 16/03/06 5 YA39 24 16/04/06 6 YA39 24 16/05/06 Page 19 90 Capel Gardens Version 5.0 7 YA42 37 8 YA42 23 9 YA42 23 results any review of quality of care and support available in the care home are published and made available to residents, stakeholders and the Commission for Social Care Inspection. It is required that significant incidents etc are reported to the Commission for Social Care Inspection. It is required that the fire bells are tested on a weekly basis with a record maintained of outcomes. Quarterly fire drill/evacuation exercises must be carried out in the care home with a record maintained of outcomes. 16/02/06 16/02/06 16/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 90 Capel Gardens DS0000017523.V269512.R01.S.doc Version 5.0 Page 21 - 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. 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