Inspection on 01/07/08 for Roland Residential Care Home (Hampden Way)

This is the latest available inspection report for this service, carried out on 1st July 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Roland Residential Care Home... 24/11/05

Roland Residential Care Home... 27/01/05

Roland Residential Care Home... 05/11/04

Roland Residential Care Home... 20/01/04

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

CARE HOME ADULTS 18-65 Roland Residential Care Home (Hampden Way) 163 Hampden Way Southgate London N14 7NB Lead Inspector Duncan Paterson Key Unannounced Inspection 1st & 10th July 2008 10:30 Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roland Residential Care Home (Hampden Way) Address 163 Hampden Way Southgate London N14 7NB 020 8368 1323 020 8211 4539 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) Mr Dushmanthe Srikanthe Ranetunge Mrs Josette Esther Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user, who is over 65 years of age, may remain accommodated in the home. This condition must be reviewed at such time as the service user is discharged and the Commission of Social Care Inspection notified. One specific service user, who has a diagnosed enduring mental disorder and a mild learning disability, may remain accommodated in the home. This condition must be reviewed at such time as the user is discharged and the Commission for Social Care Inspection notified. 11th July 2006 2. Date of last inspection Brief Description of the Service: 163 Hampden Way is a home registered to accommodate seven younger adults with a diagnosis of mental disorder. The home was registered in September 1990 and is one of four residential care homes belonging to Roland Homes, a company owned by Mr and Mrs Ranetunge. The home is an extended semi-detached house. On the ground floor there is a kitchen, a lounge/dining room and two bedrooms. One of the bedrooms has an en suite toilet. On the first floor there are three bedrooms, a toilet and a shower room. The second floor consists of a loft extension. There are two bedrooms and a bathroom on the second floor. There is a building in the garden at the rear of the premises, which contains an office, lounge (with kitchenette facilities), laundry room and toilet. The home is located in a quiet residential area, near Southgate. There are a variety of shops, restaurants and other community facilities within a quarter of a mile of the home. The home currently charges from £700 per week depending on the assessed needs of the service user. Information, including the contents of CSCI reports are available to stakeholders and a copy of the latest CSCI report is kept in the home’s lounge. The aim of the home is to provide high quality care and support to service users and to promote and maximise their independent living skills. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 3 star. This means the people who use this service experience excellent quality outcomes. This key inspection took place on 1st and 11th July 2008. The inspection involved speaking with the people using the service, the staff on duty and the manager. Mrs Ranetunge, who is a joint owner of the business, was present for the two days of the inspection. A standard form, the Annual Quality Assurance Assessment (AQAA), which had been returned earlier to us was taken into consideration, as were surveys which had been returned for the Annual Service Review which took place in March 2008. The inspection also involved the case tracking of three people’s care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. For ease of reference, the term “management team” will be used in the report to indicate that discussions were held throughout the inspection with both Mrs Ranetunge and the manager. What the service does well: The management team and staff have been successful in creating a pleasant, caring and welcoming environment for residents. The physical standards are good with a clean, comfortable and homely environment. Many of the residents said that they liked living at the home and that they got on well with staff. Earlier in 2008 we had received a number of surveys from relatives which were positive about the service. For example, one relative said, “I am happy with the overall care and security given to my relative”. Care planning arrangements are good. There are detailed care plans with a great deal of relevant information about the needs of each person. These link to comprehensive risk assessments setting out how potential risks to residents are managed. Staff said that they liked working at the home and that the manager was supportive. One said, “the best thing about working here is that I get help from the manager and that I’ve done my NVQ course”. Many staff have worked at the home for a number of years and bring a level of consistency to the service. Staff have been supported to obtain relevant care qualifications such as NVQ level 3 awards. The management arrangements are robust with the manager retaining a good overview of the service and the needs of residents. There has been attention Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 6 to detail in the keeping of records, the maintenance of a safe environment and through the regular review and update of risk assessments. The management ethos is to improve residents’ lives and provide a better quality of life wherever possible. What has improved since the last inspection? What they could do better: 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. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 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 Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12&3 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. There is clear information about the service available to all. New residents are introduced well to the home and good quality assessment information has been compiled about residents’ needs. EVIDENCE: There is a new statement of purpose dated 1 July 2008. This document covers all four of the registered services run by Roland Care Homes with a separate section for each home. The names of the registered managers are provided and there are photographs of each care home. The care homes are all for people who have a mental illness and are run in broadly similar ways. The aim of this home, very much like the other homes, is to rehabilitate residents, assist their development and independence and help them move on to more independent living. The group of four care homes enables the management team to share an oncall system with managers taking it in turns to provide out-of-hours cover. Staff, although based in one care home, may also work shifts in one or more of the other care homes in the group. This allows some flexibility when staff may be ill, on leave or on training. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 9 In order to assess the assessment arrangements individual residents’ files were inspected and discussions were held with residents, staff and the management team. There has been one recent resident admitted to the home. The other residents have lived at the home for a number of years. I spoke to the recently admitted resident and looked at the care plan. There was detailed assessment information as well as detailed background information provided by the social worker. The resident was able to confirm that the care provided was as planned. The majority of the residents were spoken with during the two days of the inspection. Some in more detail than others. Generally, the feedback about the service was positive. One resident, for example, described staff as, “helpful”. Others said that life at the home was, “good”. Residents raised some concerns about the locking of the front door and locking of the kitchen at night. This was discussed with the management team who advised that these matters had been risk assessed. They provided evidence of risk assessments that were in place. The aim being to protect residents. There had been occasions of residents losing their way whilst in the community and needing help to return to the home. However, there is a new initiative to be introduced from April 2009, the Deprivation of Liberty safeguards (DOLS), which will require this service to further assess their arrangements about door locking. A recommendation is given that a review of the arrangements in line with DOLS takes place. The returned AQAA provided details about equality and diversity initiatives. These included the provision of an accessible bathroom and toilet for people with disabilities on the ground floor as well as having a diverse staff team able to provide residents with a range of support in areas such as race, gender and disability. The staff team are diverse in terms of race, gender and ethnicity and are able to provide residents with a range of person centred support. For example, one resident is assisted to keep in touch with relatives. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 8 9 10 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The care plans in use reflect a partnership between staff and residents. Each plan is detailed with a lot of useful and relevant information about how to provide care and they are reviewed regularly. Residents have been encouraged to participate in the running of the home and given arrange of opportunities to put forward their views. EVIDENCE: In order to assess these standards the case tracking methodology was used to sample three resident’s individual case files. Discussions were also held with the residents, staff and management team. Overall, the standards were high with some very good examples of care planning arrangements. The care plans were well presented and comprehensive. Each care plan objective was accompanied with detailed entries about the work the staff were doing and what progress had been made. Residents confirmed that staff spoke with them about their needs and how they wished to spend their time. There was evidence that care plans had been developed in a person centred way. Staff provided residents with an opportunity to comment on care plans. Comments Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 11 were added to the reviews even where the resident may have disagreed with the objective. Reviews were held on a three, and six monthly basis as well as external Care Programme Approach (CPA) reviews each year. In addition, there were detailed risk assessments. For example, on one resident’s file there were risk assessments about a whole range of matters including risk to self and others, smoking, drinking and use of the front door. The care plans and other records about residents are kept securely in the home’s office. These risk assessments complemented the risk assessments provided to the service by placing local authorities. Decision making and participation at the home was discussed with the residents. It was identified that residents had a range of opportunities to participate in the running of the home. For example, there were notes of monthly residents meetings which residents confirmed they had attended. There were also notes available of regular meetings residents had with their keyworkers. Observation was made throughout the inspection of a great deal of informal discussion within the home between the staff and the residents with residents being asked what they wished to do. Within the resident group there were some differences about participation. One resident, for example, is very independent and goes out alone a great deal whilst other residents have higher needs and are more reliant on staff providing assistance. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 & 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. This judgement has been made using available evidence including a visit to this service. Care and attention has been given to making sure that residents have fulfilling lives that include opportunities for a variety of daily activities. Each person is assisted to develop a programme to suit their needs and their stage of development. Well presented meals are provided. EVIDENCE: Over the two days of the inspection the majority of the residents were spoken with and observation made of the activities they took part in. There were a variety of activities. For example, one resident attends a day centre twice a week. Other residents have less structured routines but spend time out of the home with staff carrying out everyday tasks such as shopping, swimming and leisure activities. There are links with the local community. For example, relatives visit residents and residents use the local facilities. Residents spoke about shopping trips, or Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 13 trips to see friends or to go to a restaurant on a regular basis. Residents also spoke about a recent holiday to Blackpool which had been greatly enjoyed. To assess the food and meal arrangements residents and staff were spoken to, the kitchen was visited and the serving of the evening meal was observed. There is a 31 day menu where the menu is set out for the coming month. Residents said that they liked the food provided. The evening meal was fairly modest (sausages and mashed potatoes). However, it was presented and served attractively with accompanying vegetables. The meal was served with residents eating together in the dining / living area. There are arrangements for residents who may have special diets including shopping, cooking and eating separately where desired. The kitchen was clean and tidy and efficiently arranged. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 & 20 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. There are positive relations with health care professionals and staff have made sure that residents have access to and receive relevant health care. Medication arrangements are robust and allow flexibility allowing self-medication where appropriate. EVIDENCE: Staff stressed the good working relationships that existed at the service between each other and with residents. Staff said that they felt supported and encouraged by the management team and that they liked working at the service. In turn the management team praised staff for their reliability, experience and calmness in their work. They believed that the staff consistency and expertise was instrumental in the improvements they had noted in residents’ lives. There was a friendly and relaxed atmosphere at the service with residents being open and keen to talk about life at the home. Residents said that they got on well with staff and with their keyworkers. The personal care that is provided is mainly prompting but it was evident that staff had been successful Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 15 in working with residents to address matters such as incontinence, healthy living and behavioural matters. For example, one resident confirmed that support had been given to start a regular bathing programme. There was evidence of CPA reviews as well as input from a range of health care professionals. There are positive links with health care professionals involved in the care of residents. Evidence of this was provided through letters, medication reviews and overall reviews on residents case files. There were also records of preventative healthcare appointments although staff were working with one resident to encourage a dental appointment. The resident had refused dental care up to that point. The medication policy and procedure provides clear details of how medicines are managed. The medication storage arrangements and administration records were inspected. A system of blister packs is used which makes the administration simple to follow. There were no gaps seen in the recordings of medication administered. There were documents relating to the crushing of one form of medication. A psychiatrist had agreed in writing to this. One resident self-administers medication and this is checked weekly by staff. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 & 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. This judgement has been made using available evidence including a visit to this service. The complaints system operates well with complaints made having been properly investigated. Safeguarding arrangements are detailed with a clear policy and procedure, training for staff and staff able to describe how they would respond to abuse incidents. EVIDENCE: The complaints procedure is clear and sets out the ways in which complaints can be made and how they will be responded to. Only one complaint has been recorded since the last key inspection. This had been adequately responded to with detailed records kept. The safeguarding arrangements are suitable. There is a safeguarding policy and procedure which provides a definition of abuse as well as guidance as to how to respond to incidents or allegations of abuse including referral to the local authority. Safeguarding was discussed with a member of staff. She confirmed that training had been received. She was able to describe what actions she would take should there be an incident or allegation. A more recently appointed member of staff had received safeguarding training as part of the induction to work at the unit. More detailed safeguarding training will be needed later. The money handling arrangements for residents were inspected. A sample of records were looked at. These were clearly set out with records kept of cash held in a safe at the home as well as in residents’ bank accounts. Most Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 17 residents have their own bank accounts. However, one resident for whom the organisation is the appointee does not. The management team said that they were to open a bank account for the person to bring the arrangements in line with the other residents. A requirement is given about this. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 18 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 25 26 27 28 29 & 30 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. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well maintained, comfortable home with a range of communal space and their own personalised bedrooms. The redecoration of the exterior of the home will improve the facilities. EVIDENCE: The care home is comfortable, pleasantly decorated and provides residents with a pleasant, homely environment. The home has been extended and provides a large communal area which has separate seating areas as well as a dining area. There is a pleasant garden in which residents spent time sitting in during the inspection. There is a separate building at the rear of the garden in which there is the home’s office as well as some storage space, the laundry and a lounge area with TV. Some of the residents use this room as a second lounge area. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 19 Each resident has their own bedroom. A sample of the bedrooms were seen. All were comfortably furnished and arranged with personal possessions of each resident. Some of the residents proudly lead a tour of their bedrooms. The interior of the home has been recently decorated and looks clean and neat with coordinated colours and carpets. The interior is well maintained. There are some adaptations for residents with disabilities including the ground floor bathroom. Level access can be obtained through using the rear entrance through the home’s office / second lounge area. On the first day of the inspection it was noted that the exterior of the building needed redecoration. Some of the paintwork had aged and started to peel in places. There were also two cracked windows in one of the rear bedrooms on the first floor. The management team said that their maintenance person had left and there had been a period of time where they were exploring appointing new people to do the work. New people had started to decorate one of the other homes in the group and on the second day of the inspection had started work at this home. The management team said that the cracked windows would be replaced after the redecoration. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 35 & 36 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. This judgement has been made using available evidence including a visit to this service. Staff are provided with support and relevant training. There is flexibility within the organisation’s staffing arrangements allowing a consistent service to be provided. Adjustments are needed to the recruitment process to ensure that residents are safeguarded. EVIDENCE: In order to assess this standard the staffing rota was inspected, staffing arrangements were discussed with the management team and staff on duty and a sample of staff files were inspected. The home is staffed as follows. There are two staff on duty throughout the day with the manager working usually from Monday to Friday on an office hours basis. The manager will work additional hours when required. There is one member of staff at night. Staff said that the staff numbers were adequate and that currently it was quiet at the home at the moment. The management team said that they would schedule more staff to work should the needs of residents change. Staff also said that they found the management on-call Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 21 arrangements suitable. The four managers within the group of care homes have a rota for provision of an out of hours service for the four homes. The staff team is made up of some very experienced staff as well as newer recruits. For example, one of the staff members said that she had worked at the home for more than seven years. Other staff are new and have only been working for a number of months. Evidence was provided that these new staff members had been provided with a detailed induction. There was paperwork confirming that the induction had been provided as well as paperwork detailing supervision sessions that had been provided. A new member of staff spoken with confirmed what training he had received. Through discussions with the management team it was identified that staff are expected to serve a period of time working before proceeding to further training such as NVQ training and the full range of mandatory training. Longer serving members of staff had completed NVQ courses. For example, one member of staff said she had just completed a NVQ Level 3 course). The staff supervision arrangements are good. For example, I was told that there is a monthly managers staff scheduling meeting where rotas for the four homes in the group are looked at. Having a fluid staff team allows gaps to be filled and flexibility where staff may be sick or on leave or on training courses. Each member of staff has a main file with details of recruitment, training and supervision in the care home which is their main place of employment. However, staff also have a file in other homes in which they work where there are details kept of training and supervision that is provided in those homes. A sample of these files were seen and staff confirmed that they received supervision and training in each home. However, a problem was identified with the recruitment process in relation to obtaining Criminal Record Bureau (CRB) checks for new staff. There was evidence that two new members of staff had started work without a new CRB check having been obtained by the Roland care homes group. The members of staff had CRB checks from their most recent employer. However, these are not acceptable as CRB checks are not portable within registered care homes. This was discussed with the management team. They had been advised by the Criminal Records Bureau that the previous CRB checks could be accepted as they were very recent. Unfortunately, this is not the case and a notice was issued during the inspection for new CRB checks to be obtained. The management team responded immediately and made an appointment with a CRB registered body for the staff members to obtain the new checks. A requirement is given about this. In addition, it was identified that there was a need to tighten the checking of references and obtain full work histories for applicants. There was evidence of Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 22 additional checks having been made but one applicant’s work history only went back to 2005. A second applicant’s work history was complex and the checks would have been strengthened through the references having headed paper or company stamps on them this making them more authentic. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 38 39 40 41 & 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. This judgement has been made using available evidence including a visit to this service. The manager is able to bring experience and a clear sense of direction to the service. There are effective management initiatives in place such as quality assurance and maintaining a safe environment which bring benefits to staff and residents alike. EVIDENCE: The registered manager has been the manager for four years and she worked at the home before as a care worker. She was able to express clearly the aims of the service as well as the needs of the residents. She said that she was supported and encouraged in her work by the Roland overall manager and that she had received relevant training. She has completed the Registered Managers Award. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 24 The ethos and philosophy of care is clear. The registered manager spoke about the approach taken. It was clear from the records kept and the positive feedback received from people using the service and others that the service has been successful in providing quality care that encourages residents to become more independent. The quality assurance questionnaires which had been recently returned to the service were shown as evidence. This is part of a regular quality assurance exercise. Also included in the quality assurance initiatives followed are the three monthly health and safety monitoring visits. These cover a wide range of matters including health and safety matters as well as training and are usually carried out by other managers within the group. The records of the servicing and maintenance of the home’s installations and equipment were shown. These included fire safety checks. These were all up to date and well ordered and again provided evidence of a thorough approach having been taken to record keeping. A sample of the policies and procedures were inspected and these provided evidence of attention to detail and that there was a regular review. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.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 3 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 3 3 3 3 3 3 Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 26 No 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 YA23 Regulation 20 Requirement A separate bank account must be opened for one individual resident so that benefits and other money can be paid directly to the resident. The cracked second floor rear bedrooms windows must be replaced to provide a safer environment for residents. Criminal Record Bureau checks must be obtained by the care home for all staff before they are offered work. Full details of applicants work histories must be obtained for staff before they are offered work. Timescale for action 01/09/08 2 YA24 23(2)(b) 01/09/08 3 YA34 19(1)b i Sch2 19(1)b i Sch2 15/08/08 4 YA34 15/08/08 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 YA2 Good Practice Recommendations The door locking arrangements should be further reviewed in line with the forthcoming Deprivation of Liberty DS0000010540.V366905.R01.S.doc Version 5.2 Page 27 Roland Residential Care Home (Hampden Way) 2 YA34 safeguards (DOLS). The recruitment process should involve obtaining references on headed paper or accompanied by company stamps so that they may be authenticated. Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 28 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 Roland Residential Care Home (Hampden Way) DS0000010540.V366905.R01.S.doc Version 5.2 Page 29 - 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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