Inspection on 27/07/07 for 110 Oakleigh Road North

This inspection was carried out on 27th July 2007.

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

Other inspections for this house

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 08/07/2008.

CARE HOME ADULTS 18-65 110 Oakleigh Road North 110 Oakleigh Road North Whetstone London N20 9EZ Lead Inspector Susan Shamash Key Unannounced Inspection 27th July 2007 12:30 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 110 Oakleigh Road North DS0000068406.V341234.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. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 110 Oakleigh Road North Address 110 Oakleigh Road North Whetstone London N20 9EZ 020 8445 1310 020 8883 9330 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) Willow Care Homes Ltd Paul James Clancy Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: 110 Oakleigh Road North is a registered care home providing personal care for four adults aged 18 – 65 who have learning disabilities. It is owned and run by Willow Care Homes Ltd, an independent sector provider offering a range of accommodation for people with a learning disability in the London Borough of Barnet. The home has four single bedrooms which include en suite bathrooms. An additional bathroom (containing a bath) for communal use is also available on the ground floor. The downstairs bedroom is accessible for people who have more specific needs or limited mobility. There are also a lounge, kitchen, dining room and laundry area within the home, and an office on the ground floor. The home is centrally located within easy reach of the main town and shopping area of Whetstone, with good transport links into central London and the surrounding areas. The home aims to provide a service for people with a learning disability who may have some additional health or behaviour related needs and may have a relatively high level of dependence on the support provided by staff. Weekly fees as at August 2007 are £1328.04. Recent CSCI inspection reports may be obtained from the office at the home or the CSCI website – www.csci.org.uk 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately seven hours and was carried out as a routine unannounced visit to the home. It was the first CSCI inspection of the home since it was registered last year. I received assistance throughout the majority of the inspection from the acting manager, who works alongside the registered manager for the home. It is intended that she will soon register with the CSCI as the manager of the home as the current registered manager also has many other duties as the director of the provider organisation. For the purposes of this report I will refer to the acting manager as the person in charge. I was also assisted and had the opportunity to speak to another three staff members independently and I spoke to all four people living at the home. I observed routines and staff/resident interactions at the home including the evening mealtime, and the late afternoon as the majority of people returned to the home from day services. A tour of the premises took place and care records and other records used for the running of the home were inspected. What the service does well: The home is efficiently run, with a committed staff team and good channels of communication. There are trusting and supportive relationships between staff and people living at the home. The staff team undertake effective work with people and support them to keep in contact with friends and relatives. The home is commended for providing a wide range of activities for people both inside and outside of the home, and meeting cultural and lifestyle choices and supporting people to live healthy lifestyles. There is a high level of satisfaction with the food served in the home, and people are encouraged to be as independent as possible taking part in household chores with support from staff as appropriate. People are supported to make their own choices and their preferences are respected. All people living at the home have detailed care plans that are reviewed regularly and are consulted about these. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 6 The staff team are well trained and experienced, and offer consistent support to people. They are supervised effectively and feel well supported by the home’s management. The home is decorated, furnished and maintained providing a bright and modern environment and a high standard of cleanliness with each person’s room personalised as appropriate. Detailed quality assurance systems are in place for the home to ensure that high standards are maintained and that people are consulted effectively. What has improved since the last inspection? What they could do better: Contracts with the home should be improved to further protect people’s rights. Care plans and risk assessments for people living at the home must be reviewed regularly to ensure that responsive care and support is provided. Action should be taken to ensure that people have more storage space in their rooms. Training still needed for individual staff members should be highlighted, and Person Centred Planning training should be undertaken by some staff members. The fire risk assessment for the home must be reviewed at least six-monthly and the water storage tank should also be tested for Legionella for the protection of people living and working at the home. It is recommended that a quality assurance feedback format for health and social care professionals be drafted and a record be maintained of all items stored for safekeeping on behalf of people living at the home to ensure that they are fully protected from financial abuse. Finally copies of all accident and incident forms should be kept in a central file so as to aid monitoring so that the safety of people living and working at the home can be protected as far as possible. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 7 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. 110 Oakleigh Road North DS0000068406.V341234.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 110 Oakleigh Road North DS0000068406.V341234.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, 4 and 5. 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. New residents are only admitted following detailed assessments, to ensure that the home is able to meet their needs effectively. They have the opportunity to visit and stay at the home on a trial basis, in order to decide whether they wish to live at the home. EVIDENCE: This was the first inspection of the home and all four people living at the home had been admitted shortly after the home opened. The statement of purpose for the home had already been provided to the CSCI and contains all necessary information. A service users guide (brochure for the home) is available, although it is not yet available in a format accessible to all people living at the home. In the Annual Quality Assurance Assessment for the service, the registered manager advised that he was aiming to produce this document in an easy read format within the next 12 months. It is recommended that a video or audio format be considered for the service users guide in order to be as accessible as possible to people living at the home. Records maintained within residents’ files showed that their needs had been assessed comprehensively prior to admission. There was also evidence that 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 10 their needs were being reassessed on a regular basis. Inspection of care plans and observation of support provided to people living at the home indicated that their disparate needs were being met effectively. Evidence within care files and discussion with staff members and people living at the home indicated that community professionals and previous service providers had been involved in a planned transition period prior to the move to the home. Three of the people had been living together in residential care previously and one had been living in supported living accommodation. They had all had opportunities to visit their new home and overnight stays at the home. Staff from previous services had worked some initial shifts with people at the new home, and staff from the new home had visited the previous services in order to learn as much as possible about people moving into the service, prior to the move. Each person living at the home is provided with a Statement of Services which forms the basis of the service and support that will be made available. These need to be updated to specify the room to be occupied, to ensure that people’s rights are protected as far as possible. 110 Oakleigh Road North DS0000068406.V341234.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs, choices and aspirations are assessed and monitored sufficiently to ensure that they can be met effectively. They are encouraged to make decisions about their own lives and are supported to take appropriately assessed risks to maximise their independence. EVIDENCE: Three care files were inspected and these contained detailed individual care plans for people living at the home. They are linked to initial assessments of needs and detail support for each specific area of need including health care, social activities, domestic tasks and religious and cultural needs. Support guidelines for each area of support also include risk assessments for any hazards identified for particular activities. Whilst staff and people living at the home confirmed that they are involved in producing their support guidelines and risk assessments, these are not yet 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 12 available in a format that is accessible to people living at the home. In the Annual Quality Assurance Assessment for the service, the registered manager advised that this was to be addressed in the forthcoming year. Each person living at the home has a key worker who acts as a care coordinator ensuring that all needs are addressed appropriately and that aspects of support are reviewed regularly. They complete monthly support reviews for each person and are involved in more formal review meeting after six weeks and approximately six months living at the service. Staff and people living at the home also confirmed that weekly individual meetings are arranged between people living at the home and their key workers to choose and plan activities for the coming week. However the support guidelines and risk assessments themselves, had not been updated to evidence that they had been reviewed at least six-monthly, although it did appear that this was being undertaken through the monthly support reviews. It is therefore required that reviews of these documents be recorded (dates and signatures will suffice where there are no changes to be made). Minutes of resident meetings (held monthly) indicated that people are encouraged to participate in making decisions about the home, including holiday destinations and food to be available on the menu. Observation of staff/resident interactions such as encouraging resident involvement in setting and clearing, the table after a meal, assisting with cooking etc. also indicated that they are encouraged to be involved in household routines, thus practicing independent living skills. Support with developing skills was also documented for each person living at the home, with tasks broken down into clear manageable steps. Staff and people living at the home confirmed that they were not forced to engage in activities in which they did not wish to participate, thus ensuring that their choices were respected. In the Annual Quality Assurance Assessment the registered manager advised that they were planning further review of support planning systems to work in a way that highlights abilities and enables development and achievement of long term goals and aspirations. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have a wide range of opportunities to take part in age, peer and culturally appropriate activities within and outside of the home, and support is provided in maintaining family contacts and developing independence skills. The home is creative and innovative in supporting residents with educational, and leisure activities and ensuring that their rights and responsibilities are respected. People are involved in choosing and enjoy the food provided at the home, which consists of a varied and nutritious diet that takes account of cultural preferences. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 14 EVIDENCE: People’s activity charts, care plans and daily notes indicated that a wide range of activities were available to residents both within and outside of the home. All four people were continuing to undertake their long-term day activities since moving to the home. For the most part this involves attending day centres. However recently the manager had introduced one day weekly for each person living at the home, to have a day out in the community with a staff member. One person told me that they were due to go to Greenwich with their key worker next week on their day off from the day centre, and that they would be going out for a pub lunch with the others from the home at the weekend. The registered manager also advised in the Annual Quality Assurance Assessment that people living at the home had attended an open day at Barnet college, and were being supported to consider other alternatives to full time attendance at day centres. On the day of the inspection, one person was at home during the day for part of the inspection, however other did not return from their day centres until the late afternoon. Activities at these centres included music, arts and crafts and swimming. Each person had a weekly rota of chosen activities within their care plan. No residents have jobs or are currently involved in employment related programmes. Two people are supported to attend a local Church on Sundays. Discussion with them indicated that this was in accordance with their preferences. Others are supported to undertake other activities of their choice, for example listening to music of their choosing with one person being supported to go to a Reggae music concert, which they were very excited about. There was evidence within care plans, and through observation of the evening routines in the home, that residents are encouraged to be involved in the dayto-day tasks of shared home living. People were seen helping to set and clear the table, and assisting in the kitchen with staff support. Residents spoken to had enjoyed a holiday in Pontins in Sussex this summer. Staff and residents advised that trips were arranged within the local community to visit restaurants, the pub, shopping facilities and local leisure park. Occasional barbeques are held at the home, and daily records for people also indicated that they are supported to buy magazines to read, go dancing, play dominoes and bingo. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 15 People confirmed that they are supported to visit and telephone their family members regularly, and one person advised that their girlfriend visits them at the home on a regular basis. Staff members advised that they ensure their privacy during visits by arranging for them to have meals alone in their room. Menus seen were appropriate and indicated a range of balanced meals. Food was appropriately stored and in date, and the kitchen was clean and tidy. People spoken to and observed during the mealtime, indicated that they enjoyed the food served within the home. Staff spoken to were very aware of residents’ individual preferences and cultural requirements regarding diet. The home is commended for supporting some people living at the home who were overweight to lose weight in a planned and measured manner, thus enhancing their mobility and overall wellbeing. One person living at the home, who for cultural reasons and personal preferences prefers spicy food, is provided with spicy alternatives to each meal and also has opportunities to eat Caribbean foods on a regular basis. 110 Oakleigh Road North DS0000068406.V341234.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): 18, 19 and 20. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home receive appropriate physical and emotional support in line with their preferences, and are appropriately protected by systems in place for administering medicines. EVIDENCE: Inspection of people’s care and support files showed regular input from a variety of health professionals. These included psychologists, audiologists, cardiologists, and nurses as well as regular appointments with GPs, opticians, dentists and chiropodists. The manager advised in the Annual Quality Assurance Assessment that all residents had been assessed individually by an Occupational Therapist prior to being admitted to the home. I spoke to several people living at the home, and to staff members and observed the interactions of staff and residents prior to the early evening meal in the home. Staff were seen to interact appropriately and sensitively with people living at the home, treating them with dignity and encouraging them to be independent where possible, whilst providing support when needed. They 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 17 were well informed about people’s health needs, encouraging them to eat healthily, but respecting their rights to make their own choices as appropriate. In conversation, staff spoke enthusiastically about their work, and were well informed and skilled in working with people with learning disabilities. Staff were also seen to knock and wait for an answer prior to entering residents’ rooms, toilets and bathrooms as appropriate. Storage of medication for people living at the home was appropriate, with regular monitoring of the storage temperature to ensure that it remains appropriate. Residents’ current medication and MAR charts were inspected and were complete and up to date as appropriate. Staff administering medication had undertaken training and were confident about appropriate procedures to be undertaken. Detailed medication assessments were completed by all staff members prior to administering medicine in the home, and this practice is commended. A monitored dosage system is used, provided by a pharmacy company, and records indicated quantities of medicines received every month in addition to medicines carried over from the previous month. No controlled drugs are prescribed for people living at the home. Staff were also aware of how to administer ‘as and when’ medicines, how to record medicines returned to the pharmacy and described appropriate storage arrangements should a medicine be prescribed that required refrigeration. 110 Oakleigh Road North DS0000068406.V341234.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s views are acted upon, and an appropriate system for recording and acting upon complaints ensures that they are addressed appropriately within set timescales. People are protected from abuse and self-harm, with appropriately trained staff who are proactive at identifying any issues of concern. EVIDENCE: The home has a satisfactory complaints policy, and an appropriate record of complaints received is maintained at the home including timescales by which the complaint was investigated and feedback provided to the complainant. Two complaints had been received since the home was opened and both had been addressed appropriately. There is also a format available for recording concerns from members of the staff team. Care plans and resident meeting minutes also indicated that residents’ views are listened to. Discussion with staff members and observation of procedures within the home, indicated that staff are familiar with the adult protection policy for the home and that records of any concerns are maintained as required. The local authority’s adult protection policy and procedure is available within the home, in addition to the home’s own adult protection procedures. The majority of staff had undertaken training in the protection of vulnerable adults, and a training programme was in place to ensure that newly recruited staff members also undertake this training as soon as possible. 110 Oakleigh Road North DS0000068406.V341234.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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment in which people live is bright, comfortable and safe, bedrooms reflect people’s individuality and choices as appropriate. The home is maintained to a high standard of cleanliness and decoration to ensure the comfort of residents and staff. EVIDENCE: Inspection of the building indicated that people live in a modern environment that appears to meet their needs with personalised rooms and en suite bathrooms or showers in addition to a larger bathroom for communal use on the ground floor of the home. The home throughout was found to be clean and hygienic. All residents’ rooms were inspected and these were personalised, and decorated to a high standard. However for some people living at the home, there was insufficient storage space in their wardrobes and chests of drawers to store all of their belongings. The person in charge advised that staff were 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 20 aware of this problem, and were considering ways that this might be addressed. It is required that the home conduct a review of storage space in people’s rooms, and take appropriate action to ensure that people have sufficient space to store their personal belongings. Communal areas were roomy, and comfortably furnished, and people were seen to make good use of these facilities. There appeared to be a generally open door policy for the office, so that people living at the home did not feel excluded. People were seen coming into the office to greet staff on their return from day centres, and also if they wished to see a particular staff member. Staff indicated that hot water is always available in the home, and this was confirmed by residents spoken to and during the inspection of the building. Records were also being kept of hot water temperatures to ensure that water is supplied at a safe temperature. The front and back gardens were also maintained to a high standard, and the manager advised in the Annual Quality Assurance Assessment for the home that they had further plans to introduce more shrubs and flower beds and were considering replacement of the fencing at the front of the property with more attractive railing or fencing. People living at the home were seen enjoying time spent in the rear garden during the course of the inspection. 110 Oakleigh Road North DS0000068406.V341234.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, 34, 35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected by a robust recruitment procedure, and are supported by staff who are experienced and receive appropriate training and supervision to meet their needs. EVIDENCE: Four permanent staff files were inspected and included information specified under the care homes regulations. Enhanced Criminal Records Bureau (CRB) disclosures were available for all staff with the exception of the most recently recruited staff member who was working under supervision following receipt of a satisfactory POVA first check (check against the Protection of Vulnerable Adults list). The person in charge was aware that this staff member would not be able to work unsupervised at the home until a full satisfactory enhanced CRB disclosure was received for them. Application forms, two written references and copies of identity documents were available for all staff working at the home. They also had records of supervision, induction training and further training undertaken, in the form of certificates. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 22 In the absence of the registered manager, some staff recruitment documents were forwarded to the CSCI following the inspection, and these were found to be satisfactory. The registered manager is aware that these documents should be maintained on the relevant staff files kept at the home. The supervision and training file for a member of staff who worked at the home via an employment agency was also inspected. The home is commended on providing this staff member with regular supervision sessions and a large quantity of relevant training. Inspection of staff files and discussion with three staff members indicated that people are supported by an effective and competent staff team, who have attended a wide range of training courses. Regular supervision sessions are arranged to support staff as appropriate and these are recorded. Observation of the staff rota and discussion with staff also indicated that there are sufficient staff on duty at all times to meet the needs of people living at the home and that the rota is flexible, so that extra cover can be obtained in order to support people with activities outside of the home at evenings and at weekends. Copies of staff training certificates available within staff files indicated that some staff have undertaken a wide range of training appropriate to the needs of people living at the home. This includes mandatory training such as Protection of Vulnerable Adults training, manual handling, health and safety, fire safety, food hygiene and medication administration. However newer staff members still had a wide range of training to attend. It is required that a training needs analysis must be conducted for the staff team, and an action plan is put in place to ensure that identified staff complete remaining mandatory and other relevant training courses this year. A number of staff members should also be scheduled to undertake training in Person Centred Planning to ensure that the individual needs of people living at the home are met appropriately, and that they are involved in the care planning process as far as possible. Staff spoken to advised that they were receiving support to undertake National Vocational Qualifications at levels 2 or 3. They advised that they received a high level of support from the home’s management and were confident in describing their role with people living at the home. People living at the home indicated that they were receiving a high level of support, and observations of their interactions with staff members indicated that they had formed trusting relationships with support staff, but that these were clearly defined by appropriate boundaries. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 23 In the Annual Quality Assurance Assessment for the home the manager advised that they were looking at further ways of including people living at the home in the recruitment of new staff members. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 24 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 this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well organised, and appropriately managed for the benefit of people living at the service. Monitoring systems are in place to safeguard people and ensure that their views are taken into account. The health and safety of people living at the home is promoted to a high standard to ensure that they are protected from harm as far as possible. EVIDENCE: The registered manager was not available at the home on the day of this inspection, he is also the director for the provider company, but staff confirmed that he attends the home regularly. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 25 An acting manager, who I have referred to as the ‘person in charge’ throughout this report, is currently working in partnership with the registered person to manage the home. She has over twenty years of experience of working in care settings and has just completed an NVQ level 4 qualification in Health and Social Care. She advised that she would be applying for registration with the CSCI shortly. Staff spoke highly of the support and leadership provided by both the registered manager and the person in charge. It was also clear from observing people living at the home that they held her in high esteem. The person in charge advised that a quality assurance audit for the home had been undertaken by the manager of the other home owned by the provider. This had included interviewing people living at the home about the service, staff support and other issues, and questionnaires for relatives. It is also recommended that a quality assurance feedback format for health and social care professionals be drafted, so that their views about the running of the service can be taken into account. The registered manager and director for the service had also carried out an internal audit in April 2007. Reports of these audits were available for inspection. Some clear actions taken from these surveys had already been put in place e.g. the provision of a larger car for the service. The person in charge advised that an external audit by an independent organisation was also planned for the home. In the meantime she had produced a team action plan from the internal audit results including targets for regular resident meetings, vehicle checks, medication profiles and risk assessments cross referenced to care plan guidelines. Staff and resident meetings are held at the home on a regular basis, and inspection of the minutes of these meetings indicated that these were also being used for consultation regarding food provision, resources for the home, activities etc. Monies maintained for safekeeping on behalf of people living at the home, within the office, were stored appropriately. Records for two residents were inspected and found to match the amounts stored for them in each case. Bank books and passports were stored securely on behalf of people living at the home. However it is recommended that a record be maintained of all items stored on behalf of people living at the home for safekeeping to ensure that they are fully protected from financial abuse. Satisfactory records of incidents and accidents occurring at the home were maintained, with significant events notified to the CSCI. However it is recommended that copies of all accident and incident forms should be kept in a 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 26 central file so as to aid monitoring so that the safety of people living and working at the home can be protected as far as possible. Maintenance records and safety certificates were inspected and generally found to be appropriate. A current electrical installation certificate gas safety and portable appliances testing certificates were available for the home. Fridge freezer and water temperature checks were being undertaken regularly to ensure people’s safety. Fire equipment servicing certificates were available including emergency lighting, fire extinguishers and fire alarm testing. Regular fire drills and weekly fire alarm testing are also undertaken at the home. All staff had undertaken fire safety quizzes to ensure that they are aware of safety procedures to be undertaken. Although a fire risk assessment is available for the home, this should be reviewed at least six-monthly. The water storage tank should also be tested for Legionella at least annually for the protection of people living and working at the home. 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 27 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 3 5 2 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 X 34 3 35 2 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 X 12 3 13 3 14 4 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 2 X 110 Oakleigh Road North DS0000068406.V341234.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A 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 YA5 Regulation 5(1c) Requirement Timescale for action 14/09/07 2. YA9 13(4b) 14(2) 15(2b) 3. YA24 23(2m) 4. YA35 18(1ci) The registered person must ensure that statements of terms and conditions between the home and people living at the home are updated to specify the room to be occupied, to ensure that people’s rights are protected as far as possible. The registered person must 31/08/07 ensure that care plans and risk assessments for people living at the home are signed and dated to show that they have been reviewed at least six-monthly, to ensure that responsive care and support is provided. The registered person must 28/09/07 conduct a review of storage space in people’s rooms, and take appropriate action to ensure that people have sufficient space to store their personal belongings. The registered person must 14/09/07 ensure that a training needs analysis is conducted for the staff team, and that an action plan is put in place to ensure that identified staff complete remaining mandatory and other DS0000068406.V341234.R01.S.doc Version 5.2 110 Oakleigh Road North Page 29 relevant training courses this year. A number of staff members should also be scheduled to undertake training in Person Centred Planning to ensure that the individual needs of people living at the home are met appropriately, and that they are involved in the care planning process as far as possible. The registered person must ensure that the fire risk assessment for the home is reviewed at least six-monthly. The water storage tank should also be tested for Legionella at least annually for the protection of people living and working at the home. 5. YA42 13(4a) 23(4a) 31/08/07 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. 2. Refer to Standard YA1 YA39 Good Practice Recommendations It is recommended that a video or audio format be considered for the service users guide in order to be accessible to people living at the home. It is recommended that a quality assurance feedback format for health and social care professionals be drafted, so that their views about the running of the service can be taken into account. It is recommended that a record be maintained of all items stored on behalf of people living at the home for safekeeping (including passports and bank books) to ensure that they are fully protected from financial abuse. It is recommended that copies of all accident and incident forms should be kept in a central file so as to aid monitoring so that the safety of people living and working at the home can be protected as far as possible. DS0000068406.V341234.R01.S.doc Version 5.2 Page 30 3. YA41 4. YA42 110 Oakleigh Road North 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 - 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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