Inspection on 14/08/08 for Holmdale Terrace

This is the latest available inspection report for this service, carried out on 14th August 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Holmdale Terrace 23/01/07

Holmdale Terrace 30/01/06

Holmdale Terrace 30/11/04

Holmdale Terrace 05/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Holmdale Terrace 4 Holmdale Terrace Stamford Hill London N15 6PP Lead Inspector Susan Shamash Unannounced Inspection 14th August 2008 11:45 Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 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 Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 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. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holmdale Terrace Address 4 Holmdale Terrace Stamford Hill London N15 6PP 020 8809 3638 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) albertayondah@tulip.org.uk Tulip Mental Health Group Alberta Yondah Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6), Physical disability (2) of places Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 6 adults of either gender who have a mental disorder (MD) 2 of whom may also have a physical disability (PD) 3rd January 2008 Date of last inspection Brief Description of the Service: Holmdale Terrace is owned by Circle 33 Housing Association and operated as a residential home by Tulip Mental Health Group. The home was registered in 1995 and provides care and accommodation for six people with mental health problems. The home is a terraced property located near a railway line in a quiet street in the Stamford Hill area, with shops near by. There are four single rooms and two semi-independent studio flats, which include a lounge/kitchenette and bedroom. There are two bathrooms in the house; the downstairs bathroom has been adapted to provide a walk in shower. There is a communal lounge on the first floor. The kitchen is bright and has a large wooden dining room table and chairs in the middle. Staffing at the home consists of a project manager, deputy project manager and two project workers. There are three members of staff on the early turn shift and one member of staff on the late turn shift between 5pm and 9.30pm. The home now provides an additional member of staff two evenings per week to support service users to undertake activities in the community. The principle aim of the home is to provide the emotional and practical support necessary to enable service users to exercise a degree of independence and self-determination in their lives. The weekly fees for the home as of August 2008 are £819.28 per week. Current CSCI inspection reports can be obtained from the home’s office or the CSCI website at www.csci.org.uk Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection and took approximately seven hours, so that I was able to see observe the home’s routines in the afternoon and evening. The deputy manager and two staff members were on duty for the majority of the inspection visit and provided me with every assistance throughout the visit. The manager was available towards the end of the inspection visit, and was able to provide me with any outstanding information needed. I undertook a tour of the building, spoke with five of the residents (albeit only briefly to some), two staff members, the deputy manager and the manager. I also observed the interaction between people living at the home and the staff. Further information was obtained by an inspection of the documentation kept in the home, including care plans, and health and safety documentation. Information provided in the Annual Quality Assurance Assessment for the home and surveys completed by three residents and three staff members were also taken into account. What the service does well: People have the opportunity to visit the home prior to moving in, and the home has clear and detailed assessments and care plans. The staff have a good understanding of people’s needs and residents have written contracts of terms and conditions, which are signed and up-to-date. People have access to a variety of activities and are offered varied and balanced meals. Staff support people in relation to contact with family and friends and provide residents with appropriate support to take their prescribed medicines. The cultural needs of residents are also supported sensitively. The home operates effective procedures in relation to complaints and ensures that people are consulted through regular tenants meetings. Staff are supervised regularly and receive a high standard of training to meet the needs of residents effectively. The home has a good history of compliance with requirements recommendations from the CSCI to improve outcomes for people. and The home is managed effectively with quality assurance systems in place for the home to ensure that it meets a high measurable standard. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: More accurate records should be kept of meals provided to people living at the home, with more varieties of fresh fruit made available within the home at all times, to ensure that people’s nutritional needs are met. Staff must stop secondarily dispensing an identified medicine, and guidelines should be put in place for the administration of any ‘as and when’ medicines to people living at the home to ensure that their medication needs are met safely. A small number of repairs are needed to the home environment, and TV reception in the kitchen area should be improved, as this impacts on the comfort of people living at the home. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 7 Hot water must be made available in the first floor bathroom to meet the bathing/showering needs of people living at the home, to avoid enforcement action being taken against the home. The carpet in an identified person’s bedroom must also be replaced. More frequent unannounced visits to the home by a representative of the provider organisation, must be undertaken, to ensure that a high standard of care and support is provided in the home. Finally current safety certificates are needed for water tank maintenance and electrical wiring in the home, and the building risk assessments must be brought up to date, to ensure the safety of people living and working at the home. 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. The summary of this inspection report can be made available in other formats on request. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 8 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 Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed before they move into the home so that the home can identify the support and resources necessary to address their needs effectively. EVIDENCE: One new resident had been admitted since the previous inspection. Six residents’ files were inspected and all contained clear assessment information that is being reviewed on a regular basis. The assessment process includes a six weeks assessment, which covers equality and diversity issues, and includes daily living skills and budgeting. There were also records of visits to the home by the most recently admitted resident, prior to moving in, and staff confirmed that these visits had been undertaken. It was not possible to speak to this resident as they were out during the inspection visit. Staff members spoken to had a good understanding of the individual residents’ needs, and where important assessment information was recorded. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service is good at enabling residents to make decisions for themselves about what they want to do, and in taking calculated risks to be as independent as possible. Detailed care plans and risk assessments are available for all people living at the home to ensure that their care and support needs are met effectively. EVIDENCE: Six people’s case notes were inspected and these were found to be detailed and up to date. Detailed risk assessments were also available for all residents. Care plans that I inspected were based on residents’ individual and changing needs, and including support to address people’s cultural, social and emotional needs. As required at the previous inspection, I saw evidence that the care plan and risk assessments for an identified person, whose needs had significantly increased, had been reviewed within the last six months, alongside medical reviews undertaken and correspondence with this person’s placing authority. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 11 Following discussion with the home’s manager, it is recommended that care plans should be updated appropriately prior to residents being discharged from hospital, to ensure that they are provided with support for their current needs. Clear records were maintained of each resident’s Care Programme Approach meeting as appropriate, with evidence that actions identified were being followed up by staff. Each person had a number of identified goals on which progress was being monitored and support provided by staff was clearly recorded. Signatures indicated that people were being consulted about their care plans, and this was confirmed by those spoken to. Tenants meetings, to discuss issues relating to people living at the home, take place regularly and records were available of these meetings as appropriate. A range of topics continue to be discussed including activities, relationships and current affairs. Residents demonstrated that they could make decisions and choices about their daily lives during the inspection. On the day of the inspection residents were seen undertaking a range of activities, including cooking, going out, reading and watching television. Each resident has a weekly programme of activities including a variety of day-care activities. Although there are currently satisfactory arrangements for the storage of confidential information at the home, it is recommended that there be more lockable storage space made available in the office, to further protect people’s confidentiality. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home supports people to take part in activities of their choice including those that are community based. The development and support of people’s personal relationships is taken seriously, and residents are encouraged to enjoy a healthy diet. EVIDENCE: On the day of the inspection, some residents were out at day activities such as supported employment, a men’s group, a drop-in group, and others had chosen to stay at home. I spoke with three people living at the home, who told me how they preferred to spend their time, including trips to the local shops, cinema, Wood Green shopping centre and eating out regularly. Records of resident’s activities showed that individuals had been out for walks, shopping, to the cinema, for meals out, to local parks, to church or synagogue, gardening, cooking, playing table tennis, and on a day trip to Southend-onSea. Some people had been out on day trips to various places around London Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 13 including Madame Tussuard’s, Trafalgar Square, The National Portrait Gallery and the Thames. At the previous inspection it was recommended that some new activities be offered to residents, and that given the differing tastes and preferences of people living at the home, it may be better to offer one to one activities inside or outside of the home, rather than group activities. Staff had been arranging cooking, music, discussion and film groups for people in the home, with variable interest from residents. Occasional games of chess, cards, and bingo are also offered to residents. Evidence was available that one resident continues to be supported to celebrate Jewish festivals such as Chanukah during which they are assisted to light candles and eat fried foods such as doughnuts, if they so which. An Xmas party was also held for residents at the home. Residents advised that they are supported to maintain contact with their family and friends, and this was confirmed by staff spoken to. Care plans and the visitors’ record for the home also confirmed this. Residents also told me that they enjoyed varied meals of their choice, and I saw one person cooking for themself on the day of the inspection. The home’s menu indicated that a balanced diet is provided and staff are aware of each resident’s preferences in relation to their meals and these are clearly identified in their individual care plans. I noted that a variety of fresh vegetables were available in the home, however only apples were available in the way of fresh fruit. The residents’ involvement in the completion of the weekly menu is evidenced in the tenants meetings, which take place each week. There was evidence available that residents had visited local restaurants, one resident enjoys Caribbean foods served regularly at the home, including rice and peas, and another enjoys Jewish cultural foods of their choice on a regular basis. The home had scored highly in a recent environmental health inspection of the kitchen achieving four stars – a ‘Very Good’ rating. However records of meals provided to people living at the home, were not sufficiently detailed, or current to evidence that people receive a balanced diet, and this is required. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People continue to receive appropriate support to meet their physical and emotional health needs. They benefit from effective systems in place with regard to the administration of their medication. EVIDENCE: People that I spoke with were generally positive regarding the support provided from staff working in the home. Residents’ files indicated that support was given to access appropriate medical services. I saw evidence of regular dental, chiropodist, and optician appointments for all residents, in addition to records of blood tests and contact with their GPs and relevant consultants as appropriate. As required at the previous inspection, there was written evidence, and evidence through observation, that people living at the home receive staff support to trim their fingernails. The records in relation to the administration of medication, and the storage of medication were generally found to be in order. Medication administration Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 15 records were now including details of medicines already in stock when new stocks of medicines are received. As recommended, the temperature at which medicines are stored continues to be recorded daily, to ensure that this does not exceed 25°C. As required at the previous inspection the general practice of staff secondarily dispensing medicines from their original containers (as provided by the pharmacists) into dossett boxes, to aid people who are learning to selfmedicate, had ceased. Instead the local pharmacist was providing this service, to avoid the possibility of mistakes being made through secondarily dispensing medicines. However there was one medicine that the pharmacy were not providing in a dossett box, which staff were secondarily dispensing, to aid a resident who is self-medicating. I discussed this with the manager and deputy during the inspection, and it was agreed that this practice should stop. Until this is arranged, at least two staff must sign to indicate that they have checked the contents of any medicines secondarily dispensed into dossett boxes. Shortly after the inspection, evidence was sent to the CSCI, that this requirement had been met, and the medication policy for the home had been altered accordingly. In a small number of cases, PRN (as and when) medicines were prescribed for residents living in the home, who might become particularly anxious or distressed. Records indicated that such medicines were being used very sparingly. However specific guidelines should be put in place for the administration of any ‘as and when’ medicines to individuals living at the home to ensure that their medication needs are met safely. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People feel that their views are listened to and acted upon and can be confident that they will be protected from abuse. EVIDENCE: A clear record of complaints and action taken to address each issue, is available at the home. Two complaints had been received since the previous inspection, and records indicated that these had been addressed appropriately. The manager has developed user-friendly forms for residents to express their views and make the decision as to whether they want to make a formal complaint. This also includes a complaints response form, a dissatisfaction response form and comments form. Discussions with people living at the home indicated that they felt able to talk to staff or the management about issues of concern to them, and felt that these would be taken seriously. There is an adult protection procedure, which is in place and meets the requirements of this Standard. Guidance regarding whistle blowing is contained in a separate policy and procedure. All regular staff had undertaken protection of vulnerable adult training, and those spoken to were confident about actions to be taken in the event of a suspicion or disclosure of abuse. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home benefit from living in an adequately furnished and decorated homely setting. However their comfort is compromised by insufficient hot water and improved carpet cleaning within the home. EVIDENCE: The home offers an appropriate domestic type environment. All but one resident allowed me to see their bedrooms or independent flats (the other person was out during the inspection visit) which were generally clean and tidy and contained the residents’ personal possessions reflecting their individual personalities and preferences. The kitchen was equipped with all the necessary appliances to enable residents to prepare meals and snacks. The lower oven door in the kitchen did not shut effectively so it could not be used safely, and staff confirmed that it was not currently being used. It is required that this be repaired or replaced. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 18 A recent environmental health inspection of the kitchen indicated that a high standard of hygiene procedures were in place, with a four star rating ‘very good’ awarded. Prior to the inspection, notification was sent to the CSCI of proposed changes to the home environment including, relocating the staff office so that there will be more space for staff sleeping-in, and relocating the lounge. However this work had not yet been undertaken by the time of this visit. As required at the previous inspection, there was sufficient lighting in an identified resident’s bedroom and a number of identified repairs had been carried out in this room. Repairs and redecoration in two other rooms had also been undertaken as required. The table in the lounge had been replaced and a rug had been provided in this area as recommended at the previous inspection, to make it more comfortable for residents’ use. A tour of the building showed that there was generally a reasonable standard of cleanliness within the home. However there was an odour of urine in an identified bedroom. The carpet in this room must be cleaned thoroughly regularly or replaced. All bathrooms/toilet rooms had soap provided and hand towel dispensers. There was inadequate lighting (a new bulb needed) in the downstairs shower room, but that this had been reported in the maintenance book for the home, and I received information that a new bulb was fitted there the next day. A new lino had also been fitted in this room as required at the previous inspection. New lino should also be fitted in the first floor toilet, where it is stained. However I was very concerned to learn from staff and residents that there had not been any hot water available in the first floor bathroom for approximately seven months, resulting in disruption in meeting the bathing/showering needs of people living at the home, as all residents need to use the downstairs bathroom. The deputy manager provided evidence that she had been in contact with the housing association responsible for maintenance in the home, throughout this seven month period, but the issue had not, as yet been rectified. Following the inspection she provided the CSCI with updates of correspondence with Circle Anglia, advising that an appointment had been made for a further callout in August, but the problem was still not addressed and a further appointment was made for 8th September 2008. It is unacceptable for people living at the home to be unable to use this bathroom for such a prolonged period of time, and failure to address this requirement swiftly may result in enforcement action being taken against the home. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 19 I was also concerned to note that the television reception in the kitchen area, where several residents chose to sit during my visit, was poor. A requirement is made accordingly. The garden area was well maintained, and residents indicated that they used this area frequently during the summer. The storage unit within the garden was, however in need of repair or replacement. The corridors in the home had recently been redecorated, however there had since been damage to the first floor corridor wall, caused by a door handle, and the ceiling was in need of redecorated following damaged caused by water leaking from the roof, for the comfort of people living at the home. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from clearly set out staff roles and responsibilities, and knowledge and skills that staff have developed through ongoing training and support. Rigorous recruitment procedures are in place to protect residents appropriately. EVIDENCE: The deputy manager advised that no new staff had commenced work at the home since the previous inspection and the staff team remains the same, with support from agency workers who have worked at the home for long periods of time. The staff members on duty had a clear understanding of their roles and responsibilities at the home. Regular staff meetings are also taking place and these were recorded as appropriate. The staff rota was inspected and I discussed the staffing levels with both staff and people living at the home. I also inspected other records within the home, including a record of times staff are called out at night when on sleep-in shifts. Since the previous inspection, the problem of insufficient staffing levels at Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 21 night had been addressed. Following appropriate consultation leading to the kitchen being locked at night, staff on sleeping-in duty at the home are no longer needed to get up repeatedly in the night to meet the needs of a particular resident. Four staff files were inspected, and these confirmed that rigorous checks are carried out to ensure the suitability of staff including enhanced CRB (Criminal Records Bureau) disclosures, two verified references and identity documents, as described in the Annual Quality Assurance Assessment for the home. A range of training had been undertaken by staff members including fire safety, health and safety, equality and diversity, medication administration, service user involvement, assessing needs, report writing, the protection of vulnerable adults, mental health legislation and managing violence and aggression. At the previous inspection it was required that all remaining staff complete updated training in first aid and food hygiene, and certificates were available indicating that this had been undertaken as appropriate. Records also indicated that all staff were trained to NVQ level 2 or above in care, and this was confirmed by staff members spoken to. It is recommended that a training analysis matrix be produced for the home, and that staff also be provided with training in the Mental Capacity Act 2005, to ensure that residents’ rights are protected as far as possible. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is generally managed effectively with appropriate records maintained to protect their finances. There are procedures in place to ensure appropriate quality monitoring of standards of care and support provided to people living at the home. Residents live in a home where their health and safety is actively promoted, however they are placed at risk of harm due to an insufficiently responsive maintenance system. EVIDENCE: The home’s manager is experienced at working in the field of mental health. Staff and residents continue to speak positively about the way in which the home is managed and the support provided by the manager. There is also a Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 23 deputy manager for the home, so that there are clear lines of accountability in the absence of the manager. Reports of regular monthly unannounced visits to the home by the responsible individual for the provider organisation are sent to the local CSCI area office as appropriate, although there are some gaps in the home’s records of these visits, with some missing months, and a requirement is made accordingly. The manager advised that quality assurance questionnaires had been completed by all residents in the home as appropriate, and a detailed system of auditing the quality of systems had been completed for the home. A summary of the outcome of this quality assurance audit was sent to the local CSCI area office as required. The Annual Quality Assurance Assessment for the home was detailed and indicated issues to be addressed in the coming year. The manager advised that the home had been awarded certification with the European Foundation for Quality Management model. Inspection of two residents’ monies stored by the home for safe-keeping indicated that all transactions had been recorded up to date, and were signed for by staff and residents as appropriate. Records relating to fire tests and drills were up-to-date and carried out regularly. When residents have been reluctant to leave their rooms during fire drills, records seen showed that staff had worked hard in meetings and individual key worker sessions to impress upon them the importance of fire drills to their safety. The manager had also ensured that these identified risks were recorded in the residents’ care plans and risk assessments. As appropriate the manager had consulted with the London Fire and Emergency Planning Authority in relation to the agreed action to be taken in this situation and in relation to The Disaster Recovery Plan. Records of accidents and incidents were clearly documented as appropriate and risk assessments were in place for the home environment. The homes gas safety, and portable appliances testing certificates was seen and found to be in order, however the electrical wiring safety certificate, and water tank maintenance was out of date, and this is required. Shortly after the inspection, the deputy manager updated me regarding the water tank maintenance and Legionella testing which was booked for 19th August 2008, but not yet carried out. The same was true for the electrical installation testing, booked for 22nd August 2008, and a further date, but not undertaken. She advised that this was due to delays in undertaking this work by the housing association. She advised that Circle Anglia has admitted an “abysmal performance to expedite repairs.” The building risk assessments must also be brought up to date, to ensure the safety of people living and working at the home. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 24 It is recommended that more records relating to previous years at the home, should be archived to enable easier access to current records, and that the fire risk assessment for the home should be reviewed at least six-monthly. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X 3 2 X Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA17 Regulation 16(2i) Requirement The registered persons must ensure that up to date records are maintained of meals provided to people living at the home, and that more varieties of fresh fruit are made available within the home at all times, to ensure that people’s nutritional needs are met appropriately. The registered persons must ensure that staff do not secondarily dispense any medicines. Where this is unavoidable, following consultation with the pharmacist and GP, at least two staff must sign to indicate that they have checked the contents of any medicines secondarily dispensed. Evidence was received that this requirement had been met shortly after the inspection visit. Individual guidelines should be put in place for the administration of any ‘as and when’ medicines to specific people living at the home to Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 27 Timescale for action 26/09/08 2. YA20 13(2) 12/09/08 3. YA24 23(2c) ensure that their medication needs are met safely. The registered persons must ensure that the home’s lower oven door is repaired/replaced, TV reception in the kitchen area is improved as soon as possible, and The storage unit in the garden area is repaired/replaced, to ensure the comfort and safety of people living and working at the home. The registered persons must ensure that hot water is available in all outlets within the first floor bathroom to meet the bathing/showering needs of people living at the home. Failure to comply with this requirement within the set timescale may result in enforcement action being taken against the home. The registered persons must ensure that: The carpet in an identified person’s bedroom is replaced, New lino is fitted in the first floor toilet, Damage to the first floor corridor wall, caused by a door handle is repaired, and The ceiling is repaired and redecorated where damaged by water from the roof, for the comfort of people living at the home. The registered persons must ensure that there are no gaps in the monthly unannounced visits DS0000010736.V369420.R01.S.doc 17/10/08 4. YA24 23(2j) 03/10/08 5. YA30 23(2d) 17/10/08 6. YA39 26 03/10/08 Holmdale Terrace Version 5.2 Page 28 7. YA42 13(4) to the home by a representative of the provider organisation, and that reports of these visits are made available to the home and the CSCI, to ensure that a high standard of care and support is provided in the home. The registered persons must ensure that the water tanks in the home are maintained annually and tested for Legionella, A current electrical installation certificate is obtained for the home, And the building risk assessments are brought up to date, to ensure the safety of people living and working at the home. 03/10/08 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 YA6 Good Practice Recommendations It is recommended that care plans should be updated appropriately prior to residents being discharged from hospital, to ensure that they are provided with support for their current needs. It is recommended that there be more lockable storage space made available in the office, to further protect the confidentiality of people living at the home. It is recommended that a training analysis matrix be produced for the home, and that staff be provided with training in the Mental Capacity Act 2005, to ensure that residents’ rights are protected as far as possible. It is recommended that more records relating to previous years at the home, should be archived to enable easier access to current records. It is recommended that the fire risk assessment for the DS0000010736.V369420.R01.S.doc Version 5.2 Page 29 2. 3. YA10 YA35 4. 5. YA41 YA42 Holmdale Terrace home should be reviewed at least six-monthly. Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Holmdale Terrace DS0000010736.V369420.R01.S.doc Version 5.2 Page 31 - 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. 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