Inspection on 18/07/08 for Sitara Haven

This is the latest available inspection report for this service, carried out on 18th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sitara Haven 12/09/06

Sitara Haven 10/04/06

Sitara Haven 30/09/05

Sitara Haven 12/04/05

Sitara Haven 26/08/04

Sitara Haven 13/04/04

Sitara Haven 18/12/03

Sitara Haven 03/07/03

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Sitara Haven 23 Hambrough Road Southall Middlesex UB1 1HZ Lead Inspector Susan Woolnough-Singh Key Unannounced Inspection 18th July 2008 10:00 Sitara Haven DS0000027715.V364043.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 Sitara Haven DS0000027715.V364043.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. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sitara Haven Address 23 Hambrough Road Southall Middlesex UB1 1HZ 0208 867 9590 0208 893 5342 sitarahaven@aol.com 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) Mrs Rajinder Hunjan Mrs Rajinder Hunjan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user, who has been diagnosed as having a mental illness, remains living in the home for as long as there is no deterioration which affects the well being of other service users, as agreed by the Commission For Social Care Inspection, on 1st December 2005 The home must inform CSCI when the service user no longer resides at the home. 18th July 2007 Date of last inspection Brief Description of the Service: Sitara Haven is a terraced house, located in a quiet residential street close to the shops and amenities of Southall. There are bus services close by and Southall Station is within walking distance. The home is registered for three people with learning disabilities. There is, however, a variation to the conditions of registration to accommodate a service user with mental health difficulties. The home is owned and managed by Mrs. Rajinder Hunjan and she and her family live on the premises. There are three bedrooms, one on the ground floor and two on the first floor. There is a shower room and toilet on the ground floor, and a bathroom with a toilet on the first floor. The communal facilities are shared with the owner’s family. One lounge, which is also the dining room, overlooks the garden. The other is situated in an interior room, without windows, on the ground floor. The kitchen and office are located on the ground floor. The current staff team comprises of the Registered Provider/Manager and three support staff. There are also day services provided for one person who shares the same communal facilities with the people who live at Sitara Haven. The cultural needs of the service users are being appropriately met. The current fees in the home range from £550 to £888 per week. Sitara Haven DS0000027715.V364043.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 two star. This means that people who use this service experience good quality outcomes. This was an unannounced inspection of Sitara Haven. All of the Key National Minimum Standards for Younger adults were assessed. The inspection commenced at 10.00 and was completed at 16.15. As part of the inspection process we spoke with two people living at Sitara Haven. We toured the building and examined care records, staff records and health and safety records. We received one completed survey from a person living in the home. The Annual Quality Assurance Assessment (AQAA) was completed and forwarded to CSCI; the information in this has been used as part of the inspection process. At the last inspection, which took place on 9th May 2008 six statutory requirement were made, improvements had been made and the requirements had been complied with. What the service does well: What has improved since the last inspection? The format of the care plan and presentation of information for people who use the service has improved since the last inspection. Improvements to the accommodation for people have been made since the last inspection. Parts of the home have been decorated and the garden is being well maintained. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 6 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. Sitara Haven DS0000027715.V364043.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 Sitara Haven DS0000027715.V364043.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information for people who use the service has been improved since the last inspection. People are assessed prior to moving in to the home. EVIDENCE: A revised and improved Statement of Purpose/Services Users Guide was sent to the Commission for Social Care Inspection shortly after the last key inspection. This is presented in an attractive format with pictures and clear language. There have been no new admissions to Sitara Haven since the last inspection. People who live at the home have done so for a number of years. The commissioning Local Authority carries out an assessment of need prior to people moving in. People have regular reviews. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a care plan, which reflects their daily needs and preferences. The new care plan format is an improvement on the previous format and is clear and precise. People who use the service are able to make decisions about their daily lives. EVIDENCE: We looked at the care files of all the people who use the service. At the last inspection a requirement was made for care plans to be kept under review and the goals and aspirations of people to be contained in the care plan. This had been implemented. A new care plan format has been developed since the last inspection. This contained a profile of each person with a photograph. The profile contained Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 10 information on the persons’ likes and dislikes, day opportunities, self esteem, self help skills and communication skills. Diagnosis and cognitive ability were also included. Daily care needs such as personal care; day activities’ behavioural guidelines were clearly described. People who live in the home are able to make decisions with regard to daily living such as choice of food, clothes and activities. Some of these choices are made with their support of staff. We observed that people looked clean and smart. Staff were seen to encourage people in this area. People at the home do have a low risk lifestyle. One person travels independently to a day centre; staff accompanies two people when they go out the reason for this was explained. We looked at individual risk assessments on people’s files. These covered risks on life style (health) choices and behaviour. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,12,15,16, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have opportunities for participating in the leisure and lifestyle activities they prefer and are part of the local community. Varied meals are available for people who use the service. EVIDENCE: We spoke with two people who use the service. People living at the home confirmed that they are given the opportunity to participate in the activities that they prefer. People have a number of interests such as listening to music, shopping, going to the cinema to see Bollywood and English films, and eating out locally. We spoke with one member of staff who said that trips were arranged for people who did not go out to a day service. Recent trips on the bus had made Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 12 such as visiting the Heathrow terminals including the new Terminal 5 and Waterloo Station. People were reported to enjoy this. Trips out to shopping centres in the West London area are arranged. Since the last inspection people have joined Southall College Gym. On the day of the inspection the two people at home went out for lunch with a member of staff and then in the afternoon a person who is learning English was given assistance by a member of staff. One person retuned a completed survey, he indicated that he was satisfied with the home and commented that he was very happy. The home is located in the centre of Southall within a few minutes walking distance of the Broadway. Places of worship are close to the home; including the Sikh Gurdwara and Hindu Temple. People who use the service choose whether or not they wish to attend religious worship. Family relationships are maintained and two people have relatives who visit regularly and with whom they go out. The menu reflected a variety of meals, which include Asian and English. Both English and Indian breakfast is on the menu and Indian food predominates on the menu for the evening meal. A record of the meals taken is made. One person is skilled in preparing meals. People are also able to make snacks and drinks. Fresh fruit is one the menu now and in the AQAA, encouraging people to eat more vegetables was listed as a plan for improvement. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are being supported by staff to access both the health facilitated and their specialist medical health needs. The medication administration system was satisfactory. EVIDENCE: Support for personal care is provided in line with each person’s individual needs. People who use the service may need some prompting in this area. Staff were observed to prompt people to wear the appropriate clothes for the weather conditions. Evidence was seen on the care files that health care needs are being monitored. We were able to see on care files evidence of health care visits. People had had recent visits to the Chiropodist, Dentist, Optician, Diabetic Clinic and General Practitioner. The home had identified that the monitoring of health care visits could be improved with a separate health care chart for each Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 14 person. This should also include any action or follow up to be taken after a health care appointment. Staff is responsible for the administration of medication. People are not responsible for self-administration but we were given information in the AQAA that people apply their own skin cream. A policy is in place for the control, storage, administration and recording of medicines. The Registered Manager and two members of staff give medication. Staff had been trained, in-house to administrate medication. We looked at the Medication Administration Record and the medication cabinet. The medication administration record is kept on the care file, these had been completed. Medication is delivered by Local Pharmacy and stored securely. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A new and improved complaints procedure is in place for people who use the service. Staff in the home assist people to manage their finances. There is a record in place to monitor these transactions. Staff have received training in the protection of vulnerable adults. EVIDENCE: The complaints procedure has been updated since the last inspection. This has been done in a pictorial format and is written in clear, basic English. The contact details of CSCI are given. A small change in these details is needed in line with the recent move to a Regional Contact Team. There had been no formal complaints since the last inspection. Staff have received training in the Protection of Vulnerable Adults. There have been no adult protection issues reported to the Commission. We talked with the Registered Manager about the arrangement in place for the management of finances. One person is able to manage his finances and two need support from staff. People have different arrangements in place depending on their ability and need. People had signed for the withdrawal of Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 16 money and a record was in place for one person for transactions with a running balance. Sitara Haven DS0000027715.V364043.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, 25,26, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is located in a convenient part of Southall close to shops and public transport. The home is kept in a reasonable condition for the benefit of people who use the service. EVIDENCE: People who use the service and the Registered Managers family share the communal areas of the home. There are two lounges only one of which is acceptable for the purposes of providing care. The conservatory/lounge to the rear of the building is pleasant. There is a large dining table and seating areas. A wide screen television is available with Asian Network programmes. This room looks out onto the back garden. The other lounge is an internal room between the hall and the rear lounge; there are no windows in this room. There are sofas and a television; this room was not used on the day of the inspection. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 18 Improvements have been made to the home since the last inspection. New seating has been purchased for the lounge/conservatory. The two lounges have been redecorated. Improvements have been made to the back garden with new paving, planting, and a smoking canopy. The detached building in the rear garden has now been completed. The manager said that this was a private area for the family. We were able to see people’s bedrooms; these were clean and functional and had basic furnishings. The home throughout was being kept in a clean and hygienic condition. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 19 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, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of the inspection there were sufficient numbers of staff to meet the assessed needs of people who use the service. The required recruitment procedures and employment checks are in place to safeguard people who use the service. Staff are undertaking NVQ training to ensure that they are skilled and competent. EVIDENCE: The staff team consists of the Registered Provider/Manager and three care staff. Two members of staff belong to the Registered Managers family, one of whom has recently joined the staff team and is part time. One other member of staff is employed who works part time. There is a relief member of staff who works very occasionally, about once every six months. We confirmed with the manager that the minimum of one member of staff on duty at all times is adhered to. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 20 Staff working in the home have an Asian background as do the people living in the home. One male member of staff works in the home; he is primarily involved with people if they need additional assistance with personal care. People living in the home are male. The recruitment file of one member of staff, who has recently joined the staff team, was examined to assess recruitment procedures. The newly appointed member of staff is the Registered Managers daughter. An application form, two references and CRB check were on the file. One reference was a personal reference the other from a person who had employed the new member of staff for childcare purposes. One member of staff has completed the NVQ Level 2 in Care. The Annual Quality Assurance Assessment states that two staff are in the process of completing NVQ Level 2. The Annual Quality Assurance Assessment stated that all staff had received training in food hygiene. Staff had completed training in the Protection of Vulnerable Adults in March 2007. We confirmed with the Registered Manager after the inspection visit that staff had completed training in first aid. This has taken place on 21st September 2007. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Consistency has been provided for people who use the service. A permanent staff team, who are aware of people’s care needs work in the home. Staff have received satisfactory training in health and safety matters. EVIDENCE: There have been no changes in the management of the home since the last inspection. The Registered Manager has been running the home for approximately ten years. She has the Registered Managers Award. Work had been undertaken to meet the statutory requirements set at the last inspection. The care plan format had been improved and care plans were well-presented and clearly stated people’s needs. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 22 The Registered Manager had carried out a review of the service in 2007. Questionnaires had been sent out to people who use the service and their families. The improvement plan incorporated changes made in 2006/2007, these were to continue supporting improvements in personal care and enhance the décor and offer more activities in the home. The plan for 2007/2008 is to encourage people to go to the gym, continue working towards staff gaining NVQ Level 2 and assisting one person to learn the English Language. We looked at documents relating to health and safety. Individual risk assessments were in place for people. A fire risk assessment is available for the home and was updated in January 2008. The last fire drill took place on 20th July 2008, it was identified that two people needed additional prompting to comply with the drill. Weekly fire alarm testing takes place. The Annual Quality Assurance Assessment indicates that the heating system and gas appliances were serviced in April 2008 and fire detection equipment was serviced in March 2008. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 23 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 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 3 25 3 26 3 27 x 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x 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 x 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 2 x 3 x 3 2 x 3 x Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 24 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 YA20 Regulation 13 (2) Requirement The Registered Manager must improve training for staff in the administration of medication to include:Basic knowledge of medicines. How to recognise and deal with problems associated with medication. The principles behind the homes policy on medication. Timescale for action 01/12/08 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 YA19 Good Practice Recommendations A separate record sheet of health care appointments and the outcomes of these appointments should be kept on care files. Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 25 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 Sitara Haven DS0000027715.V364043.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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