Inspection on 08/12/05 for Sampson Avenue

This inspection was carried out on 8th 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sampson Avenue 13/08/07

Sampson Avenue 04/09/06

Sampson Avenue 23/05/05

Sampson Avenue 04/01/05

Sampson Avenue 30/09/04

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 Sampson Avenue 27 Barnet Hertfordshire EN5 2RN Lead Inspector Anthony Lewis Unannounced Inspection 8th December 2005 09:00 Sampson Avenue 27 DS0000010537.V265302.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 Sampson Avenue 27 DS0000010537.V265302.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. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sampson Avenue 27 Address Barnet Hertfordshire EN5 2RN 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) 020 8449 0142 020 8449 0142 PentaHact Miss Jacqueline Driscoll Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 6 adults who have a learning disability (LD) and who may also have a physical disability (PD). 23 May 2005 Date of last inspection Brief Description of the Service: 27 Sampson Avenue is a purpose built care home registered for six adults with learning and physical difficulties. The home was opened in 1993 and is run by PentaHact, an organisation based in Finchley, North London and specialising in operating care homes and supported living projects for people with learning disabilities. Metropolitan Housing Association own the building and Metropolitan Housing Association and PentaHact maintain it jointly. The home is situated on a relatively new housing estate in Barnet. Shops and local amenities are a short walk from the home. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Thursday 8th December 2005 at 9am and was completed at 2pm. On the day of the inspection, two members of staff were off sick. The registered manger was very busy supporting the residents and staff. However, she still found the time to be available intermittently throughout the inspection process and was very helpful and understanding. To gather evidence for this inspection, six residents and six staff files were viewed along with various other files, safety certificates and documents. Two residents were spoken to, one formally and one informally. All of the core standards have been covered over the inspections year. A tour of the home was conducted with the registered manager. Overall, the home is well run by a dedicated and knowledgeable staff team, many have worked in the home for many years. What the service does well: What has improved since the last inspection? What they could do better: Ten requirements were made at this inspection, three of which have been restated. If prospective residents, their family and representatives are to have clear and accurate information about the home, a service users guide must be Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 6 produced. Residents, their family or representative must sign the contract/placement agreement to show that they are in agreement with the terms and conditions of the placement. Evidence must be recorded to show that residents participate in the day-to-day running of the home. Gaps in the medication administration record sheets where staff are not signing and not stating the reasons must be eliminated. To ensure that arrangements are handled smoothly and sympathetically, resident’s wishes in the event of them becoming terminally ill and dying must be recorded in their care plan and signed. There must be a complaints form available for people other than residents if they wish to make a complaint. All staff working in the home must have Protection of Vulnerable Adults Training to ensure that residents are protected from all forms of abuse. An effective quality monitoring system must be produced to ensure that the home is meeting the needs of the residents and that they are being provide with a quality service. To ensure that residents, staff and visitors are kept safe, all recommendations made by the London Fire and Emergency Planning Authority (LFEPA) must be complied with. To ensure that residents, staff and visitors are kept safe all appliances must be checked to ensure they are safe to use. 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. Sampson Avenue 27 DS0000010537.V265302.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 Sampson Avenue 27 DS0000010537.V265302.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 and 5. Without sufficient information regarding the service prospective and existing residents are not able to make a clear informed choice. Also, if resident’s contracts are not signed, it is not clear if residents, their family or representative are in agreement as to the provision of services and facilities. EVIDENCE: At the previous inspection, a requirement was made that the service users guide and statement of purpose be updated. The registered manager has updated the statement of purpose but when requested, she could no locate the service users guide. A requirement is made that the registered persons ensure that a service users guide is produced and a copy forwarded to the Commission. All six resident’s files were viewed and contained comprehensive assessments of their individual care needs. Residents care needs are also assessed every six months at their one to one meetings. Although each resident has a contract/placement agreement, on looking at all of them, none had been signed by the resident or their family or representative. A requirement is made that that registered persons must ensure that all residents or their family or representative sign their contract/placement agreement. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 and 9. Staff are not ensuring that residents are consulted and able to participate in the day-to-day running of the home. EVIDENCE: The staff have ensured that residents are provided with sufficient information regarding the day-to-day running of the home. However, it was not clear how residents participate in the day to day running of the home and how information is made available to them, some of whom have communication difficulties. A requirement is made that the registered persons ensure that all residents have the opportunity to participate in all aspect of the day to day running of the home and information is available to them in a format suitable to their individual needs. Each resident has their own individual risk assessments in their personal file. Risk assessments are thorough and contain information on the risk to the resident, others and the organisation and the benefits to the resident, others and the organisation. Sampson Avenue 27 DS0000010537.V265302.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): 13, 14, 15 and 16. The staff team have ensured that residents are a part of their local and wider community and are encouraged and supported to decide on what appropriate social and leisure activities to participate in. EVIDENCE: A resident was spoken to when he arrived back from his day centred. He said that he enjoys going out, especially to the park. Resident’s care plans contained information on where they like to go as part of their daily routine. All residents go to a day centre on set days of the week. Care plans viewed showed that some residents like to go to church or cinema. Care plans also contained information on what residents do not like to do. For instance some do not like going to places where there is loud music and some do not like the cold weather. On the day of the inspection, the music therapist visited and spent about an hour with a resident playing the piano to him in the lounge. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 11 The registered manager stated that all residents have contact with their family who regularly visit them at the home or that some residents will be escorted by staff to visit they family. Staff were indirectly observed knocking on resident’s bedroom door prior to entering. Throughout the inspection, the staff were observed being helpful, respectful and supportive to the residents. Residents seemed relaxed and their interaction with staff was positive. Sampson Avenue 27 DS0000010537.V265302.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): 20 and 21. Procedures are not being correctly followed with regards to recording the administration of medication, putting residents at risk. The wishes of some residents are being overlooked, which may result in confusion and insensitivity occurring. EVIDENCE: None of the residents administer their own medication. The Medication Administration Record (MAR) sheets for all residents were viewed and there were some gaps where staff had not singed after administering the medication and did not fill in the appropriate codes. A requirement is made that the registered manager must ensure that the administration of all medicines is signed for on the (MAR) sheets and any non administration coded as to the reason why the medication was not administered. On looking through resident’s files, three did not have any information on their wishes in the event of them becoming terminally ill and dying. A requirement is made that the registered persons must ensure that resident’s wishes in the event of them becoming terminally ill and dying is recorded in their care plan and signed by the resident, their family or representative. Sampson Avenue 27 DS0000010537.V265302.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 home has an effective and comprehensive complaints system in place. However, residents are being put at risk due to all staff not receiving adult protection training. EVIDENCE: The home has a comprehensive complaints policy and procedure in place. There is also a good complaints format in that there are various forms available regarding the complaints, a complaints acknowledgement form, a follow up form and complaints resolved monitoring form. Although some staff have received Protection of Vulnerable Adults training it was a requirement at the previous inspection that all staff receive (POVA) training. On looking through six staff files and speaking to the registered manager, some staff are still to receive (POVA) training. This requirement is restated. Sampson Avenue 27 DS0000010537.V265302.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, 25, 28 and 29. The staff team are ensuring that robust improvements, focusing on the health and welfare of all residents are being carried out to the home to ensure resident’s dignity is maintained at all times. EVIDENCE: At the previous inspection, a requirement was made that the carpets in the hall, office, lounge and corridors be replaced. This requirement has been met. The identified carpets have been replaced with non slip wood flooring. All shared spaces in the home are comfortable and adequate in size to meet the needs of all of the residents. The lounge and kitchen diner are bright and roomy and large enough to accommodate the residents who use a wheelchair. There was a requirement made at the previous two inspections that the facilities in the bathrooms and shower room were unsatisfactory for the residents in the home. It was recommended by an Occupational Therapist that the downstairs bathroom and the shower room be renovated and the upstairs bathroom be changed to a shower room with a ceiling track hoist. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 15 In all the Occupational Therapist made nineteen recommendations in her report. A requirement was made that PentaHact respond to the Commission in writing informing them of their actions to attend to the recommendations. PentaHact has responded in writing and the contractor assigned to carry out the work has been in touch with the Commission with their proposals for the work to be carried out. This requirement is therefore met. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 34, 35 and 36. The staff are generally well trained and competent to meet the needs of the residents and the registered manager is ensuring that the staff are regularly supervised. EVIDENCE: The registered manager and support staff were indirectly observed interacting with residents in a friendly courteous and supportive manner. When spoken to informally, staff had a good understanding of their roles and responsibilities and the needs of the residents. At the previous inspection a requirement was made that 50 per cent of staff receive National Vocational Qualification (NVQ) by 2005. The registered manager and the deputy manager have completed their (NVQ) level 3, certificates were seen in their file. The registered manager said that the deputy manager and herself are at present undertaking the (NVQ) level 4 and three staff are undertaking the (NVQ) level 2. The registered manager has ensured that the staff team understand the importance of undertaking an (NVQ) and that staff begin the training as soon as possible. In light of this it is felt that this requirement is met. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 17 Staff files viewed contained a variety of training certificates appropriate to the work that they do and meet the needs of the residents, such as moving and handling, health and safety and food hygiene. A requirement was made at the previous inspection that all staff receive a minimum of six recorded supervisions a year. On viewing six staff files, all are receiving regular recorded supervision. Sampson Avenue 27 DS0000010537.V265302.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): 38, 39, 41, 42 and 43. The registered manager’s approach ensures that residents care needs are being met and that the staff team are supported. However, service users, staff and visitors are being put at risk due to inadequate safety checks being carried out. EVIDENCE: At the previous inspection a member of staff reported that she was not happy with the way in which the registered manager speaks to her. A requirement was made that the registered manger ensure that all staff concerns are responded to and recorded. On viewing staff’s supervision file and in particular the staff member who made a complaint, evidence confirmed that the registered manager discussed the complaint with the staff member and it has been resolved and the registered manager is taking complaints seriously and recording discussions in staff’s supervision notes. Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 19 The home has a comprehensive development plan in place, which has been designed to incorporate the entire service delivery to residents. For instance, the development plan includes risk assessments, health and states issues, care plan reviewing, community participation and various other issues that impact on the service delivery. The development plan also lists recommendations, an action plan, timescale, the person responsible for various tasks and a progress update. It also contains information from surveys sent out to stakeholders, staff and the residents’ feedback. The home has appropriate polices and procedures that cover the topics in Appendix 3 of the Care Homes Regulations, which are kept in the office and are available for residents, staff and visitors to view, such as Adult protection and prevention of abuse, confidentiality and disclosure of information and fire safety. Various safety certificates, files and documents were viewed. All fire safety checks are carried out regularly and recorded. The London Fire and Emergency Planning Authority (LFEPA) visited the home on 28th February 2005 and made two recommendations, neither of which, according to the registered manager, have been complied with. A requirement is made that the registered persons ensure that the recommendations made by the (LFEPA) are complied with and a further certificates is obtained to show compliance. The lift was tested satisfactorily in June 2005. The last Portable Appliances Test and Gas safety test both occurred in August 2003. A requirement is made that the registered person must ensure that an up to date Portable Appliances Test and Gas safety test are carried. The home has policies and procedures for resident’s benefits, payment of rent and resident’s personal money. Resident’s money and the homes petty cash is kept securely in the office safe. Resident’s money and the home’s petty cash were checked and all balanced correctly. The home has a good system in place for recording resident’s and petty cash income and expenditure. Sampson Avenue 27 DS0000010537.V265302.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 1 3 X x 2 Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 2 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 x X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sampson Avenue 27 Score X x 2 2 Standard No 37 38 39 40 41 42 43 Score X 3 2 X 3 1 3 DS0000010537.V265302.R01.S.doc Version 5.0 Page 21 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 YA1 Regulation 5(1)(2) Requirement The registered persons must ensure that a service users guide is produced and a copy forwarded to the Commission. Timescale of 03/06/05 not met) This requirement is revised and restated. The registered persons must ensure that all residents or their family or their representative sign their contract/placement agreement. The registered persons must ensure that all residents have the opportunity to participate in all aspect of the day to day running of the home and information is available to residents in a format suitable to their individual needs. The registered persons must ensure that the administration of all medicines is signed for on the (MAR) sheets and any non administration coded as to the reason why the medication was not administered. The registered persons must ensure that resident’s wishes in the event of them becoming DS0000010537.V265302.R01.S.doc Timescale for action 27/01/06 2. YA5 5(c) 10/02/06 3. YA8 12(1)(2) (3)(4a) 10/02/06 4. YA20 13(2) 27/01/06 5. YA21 12(3) 24/02/06 Sampson Avenue 27 Version 5.0 Page 22 6. YA23 18(1ab) (c)(i) 7. YA42 12(1a) 23(4a) (c)v 8. YA42 12(1a) 13(4a) terminally ill and dying is recorded in their care plan and signed by the resident or their family or representative. The registered persons must ensure that all staff receive (POVA) training. (Timescale of 29/07/05 not met) This requirement is restated. The registered persons must ensure that the recommendations made by the (LFEPA) are complied with and an up to date certificate is obtained to show compliance. The registered persons must ensure that the an up to date Portable Appliances Test and Gas safety test are carried. 24/02/05 27/01/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sampson Avenue 27 DS0000010537.V265302.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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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