Inspection on 15/01/08 for Parkside

This is the latest available inspection report for this service, carried out on 15th January 2008.

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

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Parkside 25/10/05

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 Parkside Parkside 31 College Road Wembley Middlesex HA9 8RN Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 16th January 2008 10:00 DS0000063660.V355877.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 DS0000063660.V355877.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. DS0000063660.V355877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Parkside Address Parkside 31 College Road Wembley Middlesex HA9 8RN 020 8908 1268 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) Reeson Care Homes Ltd Mr Harrison Aibangbee Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places DS0000063660.V355877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2006 Brief Description of the Service: Parkside, 31 College Road is a care home providing personal care and accommodation for up to three adults with learning disability or mental health needs. It is owned by Reeson Care Homes Ltd and is the only home for that organisation. The responsible individual and the registered manager is Harrison Aibangbee. The home is situated in a quiet residential street backing on to Preston Park. The home is 10 minutes walk from local shops (Preston Road) and amenities and five minutes from the local library. There is a primary care clinic opposite the home and a GP practice nearby in the same street. It is about 5-10 minutes walk from the Preston Road where buses are available. Preston Road underground station is also about 5-10 minutes walk away. There is a parking area less than 1 minute from the home. There is limited off street parking, as most of the parking tends to be for residents’ parking. There is a shared drive where a car can be parked beside the house. The home is of similar construction and layout to other houses in the road. It has a ground and first floor with stair access. There are communal areas, kitchen shower/toilet and a bedroom on the ground floor. The additional two bedrooms are found on the first floor as well as a toilet, bathroom, office/staff room. The home now benefits from an extension, which accommodates the kitchen and dining area. All bedrooms are fully furnished and have washbasins. There is a garden that backs on to the park with access from the kitchen. The fee range reflects the complexity of the needs of residents and is currently £850.00 to £2000.00 per week. There were three residents living at the home at the time of the inspection. DS0000063660.V355877.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. The unannounced inspection took place on Wednesday 16th January from 10:20-13:20 and from 15:40-16:30. It continued on Thursday 30th January from 10:00-13:30, after I arranged with the manager to visit the home as he was not present on the 16th January. I was able to inspect a sample of records, talk to 3 members of staff and to 2 residents and tour some of the premises. The manager completed an Annual Quality Audit Assessment (AQAA) as part of the statutory duties, which was then forwarded to the Commission. The content is used where possible in this report. I would like to thank all the residents who spoke to me and made me feel welcome to the home and the manager and all his staff for their support and assistance during the inspection. What the service does well: People who want to use the service or who are referred to the home are provided with adequate information about the facilities in the home and about what the home has to offer for them to decide if they want to move into the home. Considering that residents have complex needs, the home does a good job in ensuring that the needs of the residents are met while liaising with other healthcare and social care professionals in the community. Members of staff are on the whole aware of the needs of the residents and are competent in meeting these needs. One relative commented to the home that “we appreciate the hard work and dedication that you and your staff put in” to care for a resident. Residents are encouraged to develop independent living skills and are supported to have an active lifestyle according to their views and choices. These aspects of care are addressed in the care plans. These were found to be mostly comprehensive and address most of the needs of residents. Risk assessments are also comprehensive and address the promotion of independence and development of living skills of residents. The environment that the home provides is maintained and is appropriately decorated. The atmosphere is warm and homely. Bedrooms are appropriately DS0000063660.V355877.R01.S.doc Version 5.2 Page 6 personalised and a range of furniture is provided to suit the needs of the residents. Feedback from residents about staff was positive and those who were able to speak to me said that staff are kind to them and support them in their daily life. Staff spoken to were able to give information about the residents and demonstrated that they were well aware of the needs of the residents. They also receive training to make sure that they are competent to do their job. The home has more than 50 of the staff team qualified to NVQ level 2 or above in care. Health and safety issues in the home are taken seriously and are addressed in a timely manner to ensure the safety of residents, visitors to the home and members of staff. What has improved since the last inspection? What they could do better: While care plans are generally comprehensive, thoughts should be given to making sure that the care plans for those residents who have difficulty with communication are produced in easy to read format. This is feasible as there is already one resident in the home with such a care plan. Care plans of residents should also address all the needs of residents including continence needs as well as nutritional needs. A pen picture of the resident could be included in the front of the care plan of all residents and not only in the front of care plans produced in an easy to read format. Someone reading the care plan will read about the person before getting to the needs. DS0000063660.V355877.R01.S.doc Version 5.2 Page 7 The recruitment procedures could be made more robust by ensuring that new applicants have all the necessary checks and records prior to them working in the home, as per schedule 3 of the Care Homes Regulations 2001. New members of staff must also be offered induction as per the common induction standards as per Skills for Care to make sure that they are competent to work in the home. Health and safety issues are on the whole appropriately addressed by the home. I noted that there were no thermostatic valves for the control of the hot water in the washbasin in residents’ rooms and in the bathrooms, toilets and showers. It is required that a risk assessment be carried out to address the risk of scalding. The current manager is not able to be “in full-time day to day charge of the care home”. He must therefore ensure that a full time manager is appointed who will be in day to day charge of the home and who will apply to be registered with the Commission. 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. DS0000063660.V355877.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 DS0000063660.V355877.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): 1,2 and 5 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and/or their relatives receive enough information about the service to decide if they want to use the service. The needs of prospective residents are assessed prior to them being offered a place in the home to make sure that the home would be able to meet their needs. EVIDENCE: The service users’ guide (SUG) is offered to all residents and a signed copy is available on file. The SUG is available in an easy to read format and was offered to one of the resident who has been in the home for about 2 years. A recently admitted resident however did not have one of these, which he might have benefited from. The new resident’s care records were inspected and a pre-admission assessment was noted to be in place. The needs assessment and risk assessment of the funding authority were also on file to support the home in making a decision as to whether it would be able to meet the needs of the resident. Where possible residents visit the home to meet staff and other residents prior to deciding if the home is suitable for them. The records for a newly admitted resident showed that his relatives were closely involved in the admission process and that they visited the home and continued to be closely DS0000063660.V355877.R01.S.doc Version 5.2 Page 10 involved during the trial period to support the resident with ‘settling’ in the home. I also checked two residents’ files to see whether the residents are offered the terms and condition of the placement. The terms and conditions were in the residents’ individual service users’ guides, which were signed by the residents or their relatives. DS0000063660.V355877.R01.S.doc Version 5.2 Page 11 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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans on the whole address the needs of residents within a risk assessment context, which focuses on the ability and independence of residents, for them to maintain and improve their individual lifestyle. EVIDENCE: I looked at the care records of all three residents. They had comprehensive care records. One of the residents’ care records, in addition to the usual care records, was also produced in an easy to read format. This was person centred and comprehensive and addressed the care of the resident in detail. It started with a pen history to describe the resident, which was missing from the other care records. In fact all the care plans could have had a detailed pen history in the front to provide information about the resident as a person, before looking at his/her needs and the action to take to meet the needs. I noted that all the care plans and risk assessments were drawn out with the residents or with the next of kin. DS0000063660.V355877.R01.S.doc Version 5.2 Page 12 The assessment of the needs of residents and the risk assessments were appropriately completed and were comprehensive. The care plans tended to address the promotion of independence and the development of independent living skills within a risk assessment context while maintaining the safety of residents and of others such as, staff and members of the public. It was noted that the care plans addressed the areas where residents had particular strengths. For example a resident who enjoyed art, was being supported in continuing to do art in the home and to engage in this area by attending art galleries. Another resident was supported to attend art therapy classes. Residents who were able to use a computer were being supported and the manager stated that the home was considering providing Internet access, which would also be available for residents’ use. Care plans contained information about the religion of residents and support that may require to practice their faith. There was also information in the care records about the culture and background of residents and these issues were linked into their care plans demonstrating that the home took these aspects when caring for residents. One resident confirmed that he gets culturally appropriate food. Two of the care plans and risk assessments were reviewed every six months but one of them had not been reviewed every six months. Monthly progress reviews were provided on some occasions to record progress being made by the residents. Reviews by social workers also took place and described how well the outcomes of the care plans were being achieved. There was also evidence of the home’ staff giving feedback about the progress that residents were making in the Care Programme Approach meetings. While the care plans were on the whole comprehensive it was noted that one resident’ care plans did not address a need with regards to managing continence and that another resident’s care plan did not address a need with regards to weight and nutrition. I noted that the home kept detailed entries in the progress notes, but these were not made daily on a regular basis. Sometimes there were 3-4 days before an entry was made in the care records. The home also kept separate daily handover records, which contained some information about residents. The manager stated that detailed records were made when there were significant events. There is however a need to record daily events to evidence how the plans of care are being implemented and how residents spend their day. For example residents have a daily activities plan but without a daily entry it is not possible to say whether the plan is being implemented and the activities that residents are actually involved in. The manager stated that he would ensure that daily records would be kept for each resident in the progress notes to make sure DS0000063660.V355877.R01.S.doc Version 5.2 Page 13 that all the information about one resident would be comprehensive and easily accessible to a person examining the records. DS0000063660.V355877.R01.S.doc Version 5.2 Page 14 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): 11-17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain links with the local community and with their relatives as well as engaging in appropriate social and recreational activities to make sure that they lead as fulfilling a life as possible. EVIDENCE: Each resident has an activity plan based on his/her individual interests, needs and abilities. I was informed by staff that this was followed according to residents’ wishes and level of compliance. As mentioned in the previous section residents are being supported and assisted to develop new skills and to maintain current skills. Care plans address areas where residents’ independence is being promoted and areas where they are being encouraged to develop living skills. Opportunities for personal development and appropriate leisure and social activities are also discussed in review meetings with the funding authorities DS0000063660.V355877.R01.S.doc Version 5.2 Page 15 and if necessary plans are formulated with regards to supporting residents access particular facilities. Residents are encouraged to take part in the local community within the risk assessment process. They tend to be accompanied by members of staff when they go out in the community for their own safety and for the safety of the public. There are community facilities near the home such as the library and a park. Staff said that one resident regularly goes to the library and that all residents are encouraged to go for walks. Care records seen showed that the home keeps good communication links with the relatives of the residents and that residents are supported with maintaining contact with their relatives. Staff reported that relatives are able to visit residents in the bedroom of the residents or in the communal areas. Relatives are also involved in discussing care plans and risk assessments. Records showed that they are aware of the needs of the residents and support the home in ensuring that the needs of the residents are being met. The home benefits from a well equipped and maintained kitchen. A menu is in place. Perusal of the menu showed that individual needs of residents have been taken into consideration. One of the residents has an individual menu while the other two have their meals from another menu. Staff do all the cooking, but some residents were being encouraged to take part in cooking as per their individual risk assessment. I noted that sharp cooking utensils are locked to make sure that staff and residents are safe. The menus are dated and are kept to show the meals that have been prepared for the residents. On the whole it was noted that the meals were sufficiently varied and nutritious to suit the needs and tastes of the residents. One resident who spoke to me said that the food is much better than it was previously. DS0000063660.V355877.R01.S.doc Version 5.2 Page 16 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): 17-21 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of residents are on the whole being met to a good standard. Medicines management if of a good standard and ensures the safety of people who use the service. The home addresses the aspirations and the hopes for the future of residents and their relatives in an appropriate manner to make sure that residents have realistic aims in life. EVIDENCE: All residents presented as clean and appropriately dressed. The male residents were appropriately shaved. Care plans addressed the personal care of residents and the level of support that was required by the residents. The type of clothing that residents like to wear was also addressed in the care plans. I noted that personal care was provided to residents in their bedrooms or in the bathrooms. Times that residents get up and go to bed was also addressed in care plans. One resident said that he is free to go to bed when he wants to. I noted that a resident who wanted to stay in bed was given this opportunity. Residents were DS0000063660.V355877.R01.S.doc Version 5.2 Page 17 free to move in the home. Some were seen in their bedrooms and others stayed in the communal areas. None of the residents require specialised equipment or adaptations. One resident had continence needs and although the care records did not address in detail how the needs of the resident were to be met, there was sufficient evidence to show that staff were supporting the resident as required. There were records of visits and input of healthcare professionals in the care records. It was noted that residents were receiving support from a number of healthcare professionals including the GP, psychiatrists, psychologists, dietician and community psychiatric nurses. They were also seen by the optician and dentist. With regards to whether they were seen by the chiropodist, the manager said that residents mostly do their own nails and that he would contact a chiropodist if there was a need for it. The weight of residents was closely monitored, usually weekly and in some cases the vitals signs of residents were also monitored at least monthly. This is good practice considering that residents may have hypertension. Medicines management was inspected. There is a drug cabinet in the office. Only the nurse in charge has access to the drug cabinet and the office is normally kept locked when there is no one in the office. There was a record of the sample of signatures of staff in place and it was noted that only people, who have had training in the administration of medicines, were allowed to administer medicines. Records showed that the amount of medicines that were received into the home was appropriately recorded and that medicines were signed when administered. On the whole the management of medicines was of a good standard. Care records to some extent address the residents’ expectations, hopes and plans for the future. The manager stated that these issues have been discussed with residents and in multidisciplinary meetings and with the input of relatives, to make sure that these are realistic. DS0000063660.V355877.R01.S.doc Version 5.2 Page 18 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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints and allegations and suspicions of abuse are taken seriously to make sure that residents are safe. EVIDENCE: The complaints register was empty and the manager informed me that there have not been any complaints. The complaints procedure is offered to all residents in the service users’ guide. One of the residents has it in an easy to read format and it would have been good if all residents with a learning disability could have received the complaints procedure in an easy to read format. The home has an abuse procedure. The abuse procedure for Brent was also available for inspection. One member of staff said that she would contact the manager or provider if they had concerns about residents’ abuse. The manager was also familiar with the action to take if abuse was suspected. There has not been any report of allegation or suspicion of abuse since the last inspection. DS0000063660.V355877.R01.S.doc Version 5.2 Page 19 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 the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a well maintained, comfortable and homely environment suitable for the residents who are accommodated in the home. EVIDENCE: The home is a semi-detached house with a single-floor extension at the back and is located in a residential area. It benefits from a shared drive leading to a garage/shed at the back of the home. There is some resident’s parking area on the road and more parking is available in a parking area about one minute walk from the home. The home is tastefully decorated in fresh pastel colours. It has been opened for about 2 ½ years and is relatively new. It was noted that the state of decoration and the standard of maintenance are quite good. There are a bathroom and a separate toilet on the first floor and a shower and toilet on the ground floor. DS0000063660.V355877.R01.S.doc Version 5.2 Page 20 Communal areas consist of a lounge area with adequate seating for the residents. There is a TV with cable channels, DVD player and a music system. There is also a small dining area, which consists of a table and four chairs in the new extension. The home also has a small lounge area that can be used as a quiet space, by professionals visiting the home, residents themselves or relatives/friends of residents. This new communal space has been created where the old kitchen used to be. The new kitchen is found in the newly built extension. The kitchen is well equipped with a range of domestic appliances and a range of kitchen units. Residents’ rooms are of good sizes and provide residents with ample space. I was able to see all the residents’ bedrooms. One resident has a double bed but others have single beds. They all have a range of furniture to suit their needs. Residents have televisions and music systems in their rooms and some also have their own computer. Residents are able to bring personal items to decorate their rooms and to make these homely. The bedrooms are not ensuite but there are washbasins. One resident said, “I like living in the home and I have a large room, which is well furnished and nice”. During the inspection I found that the home was clean and free from odours. There are good systems in place to manage infection control and staff are provided with protective clothing if that is required. There are wash hand basins in key areas in the home including the kitchen and there are paper towel dispensers in place. This is good practice. There was also evidence that staff have completed training on infection control as per Skills for Care DS0000063660.V355877.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35 and 36 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides appropriately trained and competent staff in appropriate numbers to care for residents. Recruitment procedures are not that robust to make sure that residents are protected by these procedures. EVIDENCE: It was noted that home’s staff team has been generally stable. The members of staff that I spoke to were satisfied with the work that they do and with the support that they receive from the manager. There were two members of staff on duty on the first day of the inspection in the morning. One member of staff went with a resident for a number of appointments at about 1200 and left two residents with a member of staff until another member of staff came on duty at 1400. I discuss this with the manager who said that the residents do not require one to one care and it was safe to leave the residents for a short period of time with one member of staff. He added that there are more staff when residents go out, for example one resident goes out with 2 members of staff, to make sure that she is safe. The DS0000063660.V355877.R01.S.doc Version 5.2 Page 22 two residents who were able to speak to me said that staff support them with their daily life and that they (staff) are kind to them. The standard of training was on the whole appropriate and staff were up to date with most of the statutory training such as food hygiene, abuse training and fire training. Some members of staff have also received Prevention and Management of Violence and Aggression (PMVA) training. I however noted that staff do not always receive training in mental health and in learning disability to understand these conditions and the associated needs of residents. The manager stated in the AQAA that 4 out of the 6 members of staff who makes the staff team have an NVQ qualification. The home therefore has more than 50 of its care staff trained to NVQ level 2 or above. In addition to that another 2 members of staff were in the process of completing NVQ level 2. I looked at the personnel files of 2 members of staff. I noted that there were gaps in the employment history of one applicant and that this area had not been explored at the point of interview. One applicant had two references and a CRB, but while looking at the dates I noted that he/she had started work prior to the CRB check and the references being received in the home. The references for one applicant were not up to date. One of the references was dated more that a year before the person was employed and the other reference was addressed ‘to whom it may concern’ and was not dated. The home has its own induction checklist that is completed as part of the induction of new members of staff, but there was no evidence that the Common Induction Standards as per Skills for Care was being completed. There was evidence that new members of staff have a probation period, when their performance is closely monitored and when they are supported to work to the expected standard. An individual development plan was also seen in the personnel records of members of staff who have had appraisals. Records showed that supervision of staff was on the whole taking place every two months. DS0000063660.V355877.R01.S.doc Version 5.2 Page 23 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 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is managed appropriately in the interest of the residents. Resident’s views are sought and considered in running and managing the service. Health and safety issues are addressed as required to make sure that staff, visitors and residents are safe. EVIDENCE: During the last inspection the situation with regards to the registered manager was discussed. This was necessary because the service provider is also the manager of the home. At the time of registration he took time off from his full time job to establish the care home, to develop the staff team and set the standards for the home that he expects. He has since returned to his full time employment. DS0000063660.V355877.R01.S.doc Version 5.2 Page 24 Regulation 8(1)(b)(iii) of the Care Homes Regulations 2001 states that the provider should appoint an individual to manage the home when the registered provider is not in full-time day to day charge of the home. The report following the inspection of 28th November 2006 states that the provider would be putting forward his deputy to be manager. At the time the deputy manager had started the Registered Managers Award (RMA). The provider confirmed that the deputy manager would be completing the RMA in April. She has however not yet been put forward as the registered manager for the home. A number of satisfaction questionnaires were noted in the care files of residents. The manager stated that satisfaction questionnaires are also sent to stakeholders to get feedback about the service. Some of these have been returned and the manager stated that he would compile a report to address the findings of the satisfaction survey. The home has a quality assurance procedure. It addresses a number of areas which are considered important to ensure a quality service including the need to carry appropriate needs’ assessment, the importance of a high standard of care plans, the quality of the home’s other records, feedback from people who use the service and the quality audit. The procedure however is not detailed enough to record the actual way that the satisfaction survey is carried out and the way that the quality audit is managed and the tool that is used for quality control. The manager has indeed developed a quality control tool based on the national minimum standard for younger adults against which the service is audited. This is commendable. The audits are carried out three monthly. I however noted that there was no action plan to address the findings of the audit. The manager stated that while completing the AQAA, he has noted that the home does not have a development plan. He stated that he would develop one. The health and safety records were inspected. The home has a fire risk assessment and a fire emergency plan. Records showed that fire drills, fire detector tests and fire emergency lights tests were carried out regularly. A gas safety certificate and a PAT testing certificate were available for inspection. The electrical wiring certificate is up to date and is valid from the date of inception of the home. The home has also carried out a health and safety risk assessment. This was generally comprehensive and addressed most areas including the low ceiling in the stairwell. There is a small sign there, but it would be helpful if this could be painted in a bright colour to draw people’s attention to it. DS0000063660.V355877.R01.S.doc Version 5.2 Page 25 The home does not have thermostatic valves to control the temperature of hot water at outlets in the bedrooms of residents and in the bath and shower rooms. It is required that the health and safety risk assessment addresses the risk of scalding in relation to the supply of hot water. DS0000063660.V355877.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 X 4 X 5 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X DS0000063660.V355877.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 YA7 Regulation 15(1,2) Requirement The care plans must address all the needs of residents including continence and nutritional needs to make sure the residents receive a high standard of care The manager must ensure that all new applicants have a full employment history and that this is explored at the interview stage if not complete in the application form. He must also ensure that all applicants have 2 appropriate references and an enhanced CRB check (or a PoVA first if the member of staff is to work supervised) before they are able to work in the home. This is necessary to make sure that residents are protected by robust employment procedures. New members of staff must complete the common induction standards as per Skills For Care to make sure that they are competent to DS0000063660.V355877.R01.S.doc Timescale for action 31/03/08 2 YA34 19 31/03/08 3 YA35 18(1)(c) 30/04/08 Version 5.2 Page 28 care for the residents 4 YA38 8(1)(b)(iii) Management arrangements must be progressed to have a full time Manager in post (Repeated requirementtimescale 01/04/07 not met) That the risk of scalding in relation to the supply of hot water in the bedrooms of residents and in the bath and shower rooms be addressed in the health and safety risk assessment. 30/06/08 5 YA42 13(4) 31/03/08 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 YA7 Good Practice Recommendations Consideration should be given to making sure that all residents with a learning disability have a care plan and other documents such as the service users’ guide in an easy to read format. That all residents have a pen picture to provide information about their ‘personhood’ That there is at least a daily record made in the progress notes to describe how the care plans are being implemented on a day to day basis. It is recommended that the home provide training to staff on mental health issues and on learning disability to make sure that staff fully understand the needs of residents as a result of these conditions. The quality assurance procedure should be clearer about the actual methods and tools used for auditing and assessing the quality of the service. Once satisfaction surveys or quality audits are carried out a report should be prepared to summarise the findings of the surveys and audits to identify areas of strengths and weaknesses. 2 3 YA7 YA35 4 YA39 DS0000063660.V355877.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 DS0000063660.V355877.R01.S.doc Version 5.2 Page 30 - 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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