Inspection on 04/11/05 for Striving For Independence Group

This inspection was carried out on 4th November 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Striving For Independence Group 02/08/07

Striving For Independence Group 10/05/06

Striving For Independence Group 26/05/05

Striving For Independence Group 20/01/05

Striving For Independence Group 22/07/04

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 Striving For Independence Group 3 Pettsgrove Avenue Wembley Middlesex HA0 3AF Lead Inspector Sue Mitchell Unannounced Inspection 4th November 2005 08:30 Striving For Independence Group DS0000017477.V262754.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 Striving For Independence Group DS0000017477.V262754.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. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Striving For Independence Group Address 3 Pettsgrove Avenue Wembley Middlesex HA0 3AF 020 8795 1586 020 8900 9633 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) Striving For Independence Group Homes Mr Otis Pinnock Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26/5/05 Brief Description of the Service: Pettsgrove is one of three homes run by Striving for Independence, a family run organisation that provides care and accommodation for adults with a range of learning disabilities and challenging behaviours. Pettsgrove provides care for 6 adults of both genders. There is a self-contained day centre in the grounds, which is used by the homes residents as well as service users from other homes in the area. The house is detached and situated in a quiet residential road in Sudbury close to local shops and transport to Harrow and Wembley. Accommodation is provided on two floors with single bedrooms and bathing and toilet facilities on each floor. There is spacious lounge ion the ground floor as well as large kitchen/ dining room and utility room. A well kept garden is to the rear of the home. There is parking for up to 5 vehicles on the driveway as well parking on the road. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. An anonymous complaint had been received by CSCI, which concerned all three SFI homes. The inspection was carried out simultaneously with the inspectors of the two other SFI homes to follow up the issues raised by the complainant. Three of the residents were at home when the inspector arrived. There were two staff on duty with two more staff arriving to carry out day care with the residents. Both staff were helpful and provided the inspector with such information that was available to them which was limited. There were no senior staff available to assist in the inspection or provide access to documents. The proprietor informed the inspector that the Manager of Pettsgrove was on emergency annual leave. The inspector was unable to access any information relating to the clients care plans, staff records or financial records until the proprietor arrived at approximately 10.30 am with the inspector from her home to view these records. The inspection focussed primarily on the issues raised by the complainant i.e. absence of managers, staff employment issues and residents finances. Some of the requirements from the last inspection were partially followed up. What the service does well: What has improved since the last inspection? What they could do better: The inspection identified a number of major shortfalls in the organisation’s staff recruitment process and employment records i.e. absence of CRB checks, lack of references, proof of identity, immigration status and permit to work in the UK. A serious concerns letter was sent to the proprietor following the inspection for them to action the above within the timescales set in the letter. Information on some of the residents finances sampled was not available in the home. The manager must ensure that all the resident’s financial records are available for inspection within the home. There was concern that care staff did Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 6 not have ready access to care plans or information on residents. The manager must ensure that this information is made available for both staff and inspectors at all times. The homes training programme had not been supplied as required from the last inspection and is outstanding. The absence of the manager on this occasion was of concern as there was no designated responsible person on duty to manage the home or to provide essential information for the inspectors. The manager must ensure that there is a designated responsible person on duty when he is unavailable or on leave. The proprietor must ensure that she carries out Regulation 26 visits to each of the homes on a monthly basis and supplies the CSCI office with copies. 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 DS0000017477.V262754.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 Striving For Independence Group DS0000017477.V262754.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: Not assessed on this visit. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The resident’s main care files are not readily available for staff to refer to, nor are the in house care plans kept updated EVIDENCE: The inspector did not have access to the main care files due to the absence of the manager and administration officer when the inspector arrived. There was a folder, which contained the care plan sheets for each person. There were no dates on the care plan when the plans were reviewed or when tasks were achieved. This is required. A senior staff member who came on duty during the inspection stated that work was in progress regarding the requirements relating to the care plans but no information was seen on this occasion. The manager must ensure that care planning information is readily available for both staff and inspection at all times. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15,17 Residents benefit from a range of social activities and day care programmes. They are supported to maintain regular contact with family and friends. They are provided with a range of healthy meals. EVIDENCE: Three of the residents attend a day centre in Brent and had left for the morning. The remaining residents along with some from other homes went to the home’s day centre, which is based in the grounds of Pettsgrove Ave. The staff informed the inspector that the residents had not had a holiday this year but had had a day trip to Alton Towers in the summer as well as their weekly trips to parks, zoos etc. The proprietor informed the inspector that she was planning to take the residents on two holidays next year as there had been problems with booking this years holidays. The inspector was informed that all but one person has family contact either through visits from or to relatives as well as cards for birthdays and festivals. The menu was on display and indicated a range of traditional and cultural meals. The residents in the day centre came into the home for their lunch break. They were observed to enjoy their meal. Striving For Independence Group DS0000017477.V262754.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): 18,19,20 There is limited information available on residents’ individual preferences. They are supported by staff to attend all health care appointments within the local community. Medication practices are safe. EVIDENCE: One of the care staff stated that the key workers were writing personal care profiles for the residents, which had been required from the last inspection. The inspector was informed that these were being typed up at present and were therefore not available during the inspection. They will be reviewed at the next inspection. The information must be readily available for staff and inspection at any time. The residents’ health care appointments were kept in a separate folder and made available for inspection. There was a clear record of all visits to the local health care services and outcomes of appointments were in place. A medication error had been identified during the last inspection and the manager had been required to provide refresher medication training for staff. Staff spoken to confirmed that this had happened. The medication records were inspected, no errors were found. Striving For Independence Group DS0000017477.V262754.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): 22,23 The residents’ day-to-day finance records are well kept but the manager must ensure that they have access to their bankbooks and records of any payments made to them or expenses carried out on their behalf. There is a complaints policy in place. EVIDENCE: An anonymous complaint had been received by CSCI about SFI and concerned all three homes. This inspection focussed on the issues raised by the complainant, the findings of which are documented within this report. The areas of concern were, staff recruitment checks, service users finances and absence of managers on site. A number of requirements were made in relation to the concerns raised in a letter sent to the Proprietor following the inspection. There had been no other complaints made to or about the home since the last inspection. Only one resident is able to verbalise concerns. This person was not present on this occasion to ask whether they had any complaints. There is a service users finance policy in place. Two of the resident’s day to day finance records were sampled. The money and records were noted to be correct. The resident’s bankbooks were not in the home. The proprietor stated that they were with the accountant. Another person is under a Court of Protection but there were no records on receipt of his money or how his money is spent on his behalf. This is required. The inspector was informed that the way in which residents benefits are to be paid were changing. The homes residents’ finances policy and procedure must be amended to reflect these changes. A serious concerns letter was sent to the Proprietor in relation to the financial records with timescales for them to action the requirements. Details of these requirements are in the requirement section of the report. Striving For Independence Group DS0000017477.V262754.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 The residents live in a well maintained, clean and odour free environment EVIDENCE: The inspector toured the premises. The bedrooms were found to be very cold as the windows were open to air the rooms. The bedrooms were comfortably furnished, as were the communal areas. The home was clean, tidy and free fro m odours. Striving For Independence Group DS0000017477.V262754.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): 32,34,35 Residents’ care is provided by a regular group of staff, some of who work across all the homes. The recruitment practices of the home were found to inadequate and did not provide sufficient evidence that the home was protecting the residents through rigorous checks. EVIDENCE: The complainant had raised concerns about the organisation’s recruitment practices. The inspectors reviewed the staff files for the three homes. The inspectors found that a number of staff files did not contain key information such as CRB checks, work permits, student/visitor status and agreed right to work in the UK, two references and identity details. The proprietor was present during the inspection of these files. A serious concerns letter was sent to the Proprietor with details of the information required and timescales for managers to carry out these requirements. Details of these requirements can be found in the requirement section of this report. The rotas for each home were made available. Some staff were noted to work in more than one of the homes. The manager is required to ensure that there is a record of the total number of hours worked by these staff each week. A training programme for the home had been required to be provided for inspection during the last inspection. This was again not made available for inspection. Training records were not inspected on this occasion but the staff on duty confirmed that they had had recent training on first aid, epilepsy and medication. One staff member said she was looking forward to starting her NVQ2 that week. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 15 Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 16 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): 37,39,40 The residents and staff would benefit from having a designated responsible person on site in the absence of the manager. The residents and staff would benefit from having monthly quality monitoring visits by the provider. EVIDENCE: The inspector was informed that the manager was on emergency leave. He came to the home briefly but did not participate in the inspection. He had been required to supply the CSCI with a copy of his job description. This had not been actioned and is now outstanding. The proprietor informed the inspectors that deputies for each home had been appointed to support the managers. The deputy for Pettsgrive was not in the home until some time after the inspection started. The manager must ensure that the deputy or designated responsible person is rota’d to cover in his absence to deal with inspection or other activities that need management attention. Staff informed the inspector that they had a copy of the home’s policies and procedures manual available for them in the kitchen. This was shown to the inspector and the staff member was able to identify key polices within the manual. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 17 The inspector discussed the homes quality assurance system briefly with the proprietor, as the manager was unavailable. They have a service quality report in place, which is used by the proprietor. Copies of these reports had been sent to the CSCI in error. The proprietor had been required to carry out monthly Regulation 26 visits to all three homes and to send copies to CSCI. The inspector agreed to forward copies of Regulation 26 proformas to the Proprietor for her to use. The proprietor informed the inspector that staff and residents questionnaires were in place. Due to the absence of the home’s manager this standard was not assessed in full on this occasion. Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Striving For Independence Group Score 2 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X X X DS0000017477.V262754.R01.S.doc Version 5.0 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement The manager must ensure the key workers record dates of reviews and when tasks are achieved. The manager must ensure that care planning information is readily available for both staff and inspection at all times. The manager must ensure that key workers write personal profiles and activities of daily living which incorporates the skills that the residents require support with on a daily basis (ref Standard 18.1.i) This information must be made available for staff at all times and inspection (Previous timescales of 28/02/05 and 31/07/05 not met) The residents’ savings account books must be kept in the home and be made available for inspection. That records are kept and must be made available for inspection of the money received and spent on behalf of the person who is under Court of Protection The homes policy and procedure DS0000017477.V262754.R01.S.doc Timescale for action 31/12/05 2 YA6 15,17 31/12/05 3 YA18 15 31/01/05 4 YA23 16(l), 20 31/12/05 5 YA23 16(l) 17,20 08/12/05 6 YA23 20 06/12/05 Page 20 Striving For Independence Group Version 5.0 7 YA32 18 for handling residents finances must be amended to reflect the changes in the payment of benefits The manager is required to ensure that there is a record of the total number of hours worked each week by staff working in other homes within SFI. Enhanced CRB disclosure application forms must be completed and submitted by 20/11/05 for the 5 staff members who did not have a CRB closure and for the 3 staff who have provided CRB disclosures obtained prior to their employment with SFI That all files for staff members employed since 01/04/02 must contain 2 satisfactory references All staff files must contain proof of ID The files of staff members who do not hold a EU or UK passport must have evidence of their right to work in the UK and that right to work is valid The files of staff members who have student or visitor status must contain information confirming their right to work and any other restrictions i.e. number of hours allowed to work per week A training programme for the home must be in place (Previous timescale of 31/07/05 not met) The manager must ensure that the deputy or designated responsible person is rota’d to cover in his absence to deal with inspection or other activities that need management attention DS0000017477.V262754.R01.S.doc 14/11/05 8 YA34 19 Sch 2 20/11/05 9 10 11 YA34 YA34 YA34 19 Sch 2 19 Sch 2 19 SCH 2 06/12/05 06/12/05 06/12/05 12 YA34 19 Sch2 06/12/05 13 YA35 18 31/12/05 14 YA37 9 31/12/05 Striving For Independence Group Version 5.0 Page 21 15 YA37 9 16 YA39 26 A copy of the managers job description must be sent to CSCI (Previous timescale of 31/7/05 not met) The proprietor must carry out monthly Regulation 26 visits the home. Copies of the reports must be sent to CSCI 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 22 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 Striving For Independence Group DS0000017477.V262754.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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