Inspection on 26/05/05 for Striving For Independence Group

This inspection was carried out on 26th May 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

Striving For Independence Group 02/08/07

Striving For Independence Group 10/05/06

Striving For Independence Group 04/11/05

Striving For Independence Group 20/01/05

Striving For Independence Group 22/07/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

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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 Striving For Independence Group 3 Pettsgrove Avenue Wembley Middlesex HA0 3AF Lead Inspector Sue Mitchell Unannounced Inspection 26th May 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. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Striving For Independence Group Address 3 Pettsgrove Avenue, Wembley, Middlesex, HA0 3AF 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) 020 8795 1586 020 8900 9633 Striving For Independence Group Homes Mr Otis Pinnock Care Home 6 Category(ies) of Learning Disability registration, with number of places Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th January 2005 Brief Description of the Service: Pettsgrove Ave is one of three homes run by the Striving for Independence organisation, which provides accommodation and care for adults with learning disabilities and challenging behaviours. Pettsgrove Avenue is situated in a quiet residential area of Sudbury close to local shops in Sudbury and Wembley. There is good access to local transport services and leisure facilities. The house is detached and the property is on two floors, with residents bedrooms and bathing and toilet facilities on both floors. There is a separate kitchen/ dining area and a spacious lounge. There is a well kept garden at the rear of the property. There is off street parking for approximately 5 vehicles although it is also possible to park in the street. There is a separate day centre to the rear of the house, which is used by some of the residents from the three homes as well as providing a service for people from other homes in Harrow and Brent. Some of the residents attend Brent Council day centres. The home has its own transport, which is used regularly to take the residents and day centre users out on trips. The organisation is a family run business and the registered Care Manager is the son of the proprietor Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector made her first visit on 25th May but the residents were out on a day trip. A second visit was arranged for the following day. The inspection took place during the afternoon and early evening when the residents were home from the day centres. The residents have a range of learning disabilities and challenging behaviours. All but one of the residents has limited verbal communication. They use signs, gestures, physical contact and some speech, which was mostly repetitive or single words, to indicate their needs. One person spoke to the inspector when he came home. He spoke about his day at the centre, his planned holidays, his family and other social activities. The inspector spoke to the staff on duty, the manager and the proprietor who were in the home during the inspection. The inspection focussed on care plans, health care and other records, medication, health and safety, staff training and supervision What the service does well: What has improved since the last inspection? What they could do better: There was discussion during and after the inspection with the manager about the increasing demands on his role within the home. He has dual responsibilities within the organisation as he is the finance manager for all three homes. The organisation must keep this under regular review as the manager needs to be accountable and responsible for the day to day management of the home as the Registered Manager. A number of requirements were made in relation to the manager’s responsibility to ensure action was taken to improve care records and information on the residents, medication training and recording. There was no training programme for Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 6 2005-2006 for the home. The manager must ensure that if he does not supervise his team then those who carry out this role must be competent and suitably trained. A recommendation was made to make the service users guide more user friendly by having pictures and large print rather than small symbols. Working care files were also recommended to ensure that up to date information was made available for staff and inspection. The inspector also recommended that key workers write monthly summaries on significant events and issues in the resident’s lives. The proprietor is required to carry out monthly Regulation 26 visits to her homes and sent a report to the CSCI. 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. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 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 Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 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 Prospective residents and their families have access to information about the home’s admission procedure and services provided. EVIDENCE: The home had been required to update and amend its Statement of Purpose. This has now been completed. A service user guide had also been written using small symbols and words (widget symbols). The inspector judged the document to be too complicated for people with profound learning disabilities to understand and recommended that the document be revised using pictures of the home, resident’s activities in and out of the home, using large print and more simplistic language. The manager stated that he would take this on board The residents have been in the home for a number of years and there are no vacancies. The inspector was informed that funding had been applied for, for one to one support for one resident who had very challenging behaviour, which was increasing. The home has an admissions and assessment procedure in place. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 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) 6,7.9 The residents are supported to achieve their goals through regular reviews of their care plans. They have the opportunity to express their wishes at regular house meetings. The residents are supported to take risks within a safe environment EVIDENCE: The home had been required to write personal profiles for residents, which would reflect some of their daily living skills goals as identified in their reviews and care plans. The manager stated that this work was ongoing but there was no written evidence to substantiate this. Two care files were inspected. All information on the residents was in these files. It had been recommended at the last inspection that a working care file folder for each resident be made up to contain all current working documents such as the last review, care plan, risk assessments, behaviour management guidelines etc. This had not been achieved. There was a folder for staff use, which contained the new key working documents, which had been put into place following the last inspection. They contained details on care plan goals, health care appointments etc. Not all the key working information had been completed. There were also positive behaviour assessments with strategies for prevention and action. The home uses daily diaries to record all the resident’s activities. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 10 It was recommended that monthly summaries be written to ensure that key information is recorded for use at reviews The home holds monthly residents meetings, which are minuted by staff. Views of residents are recorded in terms of requests for activities etc. Only three people have speech, of which two have repetitive speech. There are detailed risk assessments in place as well as a missing persons policy and procedure. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 11 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) 12,13 Residents are supported to participate in community activities and enjoy a range of social and leisure activities. EVIDENCE: The home has a planned day out each week for the home’s day centre users, which includes the residents living in the home. Some trips are to local parks etc. A number of full days out to Brighton, Whipsanade and London Zoos, Kew Gardens, Woburn Safari Park are planned for the summer months. The residents who attend the day centres in Brent are included in these day trips. Each person has a daily activity chart. The homes day centre provides a range of activities for the residents to enjoy such as music, art, pottery walks to local parks etc. The residents also attend local clubs such as the Apple Club and Gateway club. The resident who spoke to the inspector said that he enjoyed the clubs because there were discos and he enjoyed dancing. He had won a prize for disco dancing when he was on holiday in Portugal last year. Staff said that holidays for the residents were being planned for September. One resident said he was looking forward to having two holidays this year; one with the Gateway Club and one with the home. He said he’d like to go back to Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 12 Portugal and enter the dance competition again. Some of the residents have gone to Center Parcs or Butlins in the past, as they aren’t able to fly. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 13 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 Residents are supported to attend local health care services within the community. There is support from appropriate health care professionals to assist in the management of behaviour and medication. Information on the resident’s personal routines and preferences is not clearly documented. Staff require further training on the safe handling and administration of medication to protect service users from harm. EVIDENCE: As detailed in standard 6 the home had been required to provide a personal profile of each resident outlining personal routines and preferences, this has not been achieved. The home keeps detailed records of all the resident’s health care appointments with outcomes. The residents are supported to attend local health care services in the community. The home has contact and support from the psychiatrist who also monitors the resident’s medication. Whilst checking the medication records the inspector found a medication error whereby the evening medication for two people had been given to them in the morning by mistake. This information had not been passed to the manager who was absent that morning at a meeting. This information was not recorded in the handover file. The proprietor said she was in the home when this happened and had dealt with the situation. She said she had contacted the appropriate agencies to ensure that there would be no side effects. The inspector required the manager to send in a Regulation 37 notification of Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 14 significant events to CSCI with details of the incident and action taken. Regulation 37 forms were sent to the CSCI office the following day. As a result of this incident the manager is required to ensure staff have refresher training on the correct procedure for the administration of medication. All other aspects of this standard were noted to be satisfactory. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 15 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) 23 The residents are protected from harm through the home’s adult protection policies and procedures. Staff have appropriate training in abuse awareness. EVIDENCE: The home has a comprehensive abuse awareness policy and procedure in place. A copy of the Brent Protection of Vulnerable Adults guidance is in the home and the home’s guidance refers to the procedures to be followed. The proprietor stated that staff have had in house abuse awareness training as well as having the adult protection officer from Brent to discuss abuse awareness with staff. The home has comprehensive procedures for managing verbal and physical aggression, whistle blowing and residents finances. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 16 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 The residents live in a clean, well furnished and odour free home. EVIDENCE: The inspector did not tour the home on this occasion. The communal areas were noted to be clean and free from odours. There have been no changes to the premises since the last inspection. The proprietor stated that she was having stainless steel skirting boards put in the kitchen for cleanliness. The Fire Brigade had inspected the home on 19.5.05; there were no issues from this visit. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 17 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) 34,35,36 Residents are supported by a well trained and competent staff team. Staff receive regular supervision and training to ensure they are meeting residents needs. EVIDENCE: The inspector sampled two new staff files. These were noted to contain all the information required under Schedule 4.6 of the Care Homes Regulations 2001. The home does not have an up to date training programme for 2005-06. The inspector was informed that training in first aid, food hygiene, infection control, moving and handling, fire safety and abuse awareness was planned for this year. Staff spoken to confirmed that they had had training. One person has also completed their NVQ3. The manager had been required to ensure that records were kept of staff supervision. The two files sampled contained recent supervision records. The inspector was concerned to be told that the manager does not supervise his staff. In a letter sent to the CSCI following the inspection the manager stated that this is carried out by the organisation’s Human Resources manager who is also the manager of another home in the organisation. She supervises the senior staff in the homes who then supervise the support staff. Following the inspection the manager sent copies of the supervision training recently undertaken by the senior staff in the organisation. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 18 Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 19 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) 37,38,42 The resident’s health, safety and welfare needs are protected through regular checks of the home and staff training. The manager may not be able to carry out his management role within the home due to other commitments. EVIDENCE: The manager informed the inspector that he has dual responsibilities within the organisation as he is the Finance Manager for all three homes and manages the finances and pay roll. The manager informed the inspector that the organisation had been restructured so that each home manager had particular responsibilities. The Human Resources manager is responsible for staff supervision and training and carries out the supervision of senior staff in all the homes. The organisation must keep this under regular review, as the manager needs to be accountable and responsible for the day-to-day management of the home as the Registered Manager. A copy of the manager’s job description must be sent to the CSCI The proprietor stated that she comes into the home on a daily basis as the clients living in the home she manages attend the day centre there. She also Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 20 said she is responsible for the care and welfare of the residents in all three homes. She does not carry out formal Regulation 26 visits. This is required. She must arrange for these visits to be carried out monthly and the reports sent to the CSCI. All certificates relating to the equipment and appliances in the home were made available for inspection. These were found to be up to date. There are robust health and safety policies in place. Staff have either had or are due to have appropriate health and safety training. The home benefits from having a handyman who carries out minor repairs in the home. He also carries out health and safety checks of the building. The home has had visits from the Fire Brigade and Environmental Health Officer in the past year. Risk assessments of the building and a fire risk assessment have been carried out. Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x x Standard No 31 32 33 34 35 36 Score x x x 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Striving For Independence Group Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 2 x G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 22 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 6.18 Regulation 15 Requirement Timescale for action 31.7.05 2. 20 3. 20 4. 5. 35 36 6. 7. 37 38 The manager must ensure that key workers write personal profiles and activities of daily living which incorporates much of the skills that the residents require suppoet with ina daily basis (Ref Standard 18.1 .ii) (Previous timescale of 28.2.05 not met) 18(1)(a)(c The manager is required to )(i) ensure staff have refresher training on the correct procedure for the administration of medication. 37 The manager must ensure that staff inform CSCI of all events or incidents, which adversely affect the well being or safety of residents 18(1)(i) A training programme for 200506 must be in place 18(1)(2) The manager must provide evidence that the senior staff who supervise staff in Pettsgrove are competent and have had training in supervision. 9 A copy of the managers job description must be sent to the CSCI office 9 The organisation must keep the managers role and G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc 31.7.05 Ongoing 31.7.05 31.7.05 31.7.05 From 26th May 2005 Page 23 Striving For Independence Group Version 1.30 8. 42 26 responsibilities under regular review as the manager needs to be accountable and responsible for the day to day management of the home as the Registered Manager The proprietor must carry out monthly Regulation 26 visits to the home and supply the CSCI with a copy each month. and ongoing From June 2005 and be ongoing 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 1 Good Practice Recommendations It is recommended that the service users guide be revised using pictures of the home, resident’s activities in and out of the home, using large print and more simplistic language It is recommended that a working care file folder for each resident be made up to contain all current working documents such as the last review, care plan, risk assessments, behaviour management guidelines etc. It is recommended that monthly summaries be written to ensure that key information is recorded for use at reviews 2. 6 3. 6 Striving For Independence Group G62 S17477 3 Pettsgrove Ave V225647 250505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 4TH 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. 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