Inspection on 16/01/07 for 237 Kenton Road

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

237 Kenton Road 24/02/06

Similar services:

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 237 Kenton Road 237 Kenton Road Kenton Harrow Middx HA3 0HQ Lead Inspector Andreas Schwarz Key Unannounced Inspection 16th January 2007 09:30 237 Kenton Road DS0000030898.V303337.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 237 Kenton Road DS0000030898.V303337.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 Older People and 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. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 237 Kenton Road Address 237 Kenton Road Kenton Harrow Middx HA3 0HQ 020 8907 6953 020 8907 2896 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) www.caretech-uk.com Caretech Community Service Limited Nicola Bober Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: 237 Kenton Road is a care home providing personal care, and accommodation for 12 adults, and older people who have a learning disability. Care Tech Community Service Limited home owns the care home. There is accommodation for six residents in a ground floor unit, and accommodation for six residents on a first floor unit of the care home. Each unit is self-contained, with separate front entrances, and enclosed gardens. The bedrooms are all single, and each unit has its own communal space, toilet and bathing facilities, kitchen, and office. There were two vacancies on the ground floor unit at the time of the unannounced inspection. The home is located in Kenton, within a few minutes walk or drive from Harrow. The home is close to a variety of shops, restaurants, pubs, a post office and other amenities. There are bus and train public transport facilities located close to the home. There is parking for several vehicles on the forecourt at the front of the house. Fees and charges can be obtained from the registered manager. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place during a day in January 2007 and lasted 8 and ½ hours. The registered manager Mrs Nicola Bober was present throughout this inspection. The inspector spoke to one resident at lengths and met five other residents living at the home. The inspector observed staff working with residents and spoke to four staff members during this key inspection. The inspector assessed care plans, financial records, policies and other records relating to the home and care provided. The inspector would like to thank everybody involved in this key inspection for their friendliness, assistance and transparency. What the service does well: What has improved since the last inspection? 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 6 The home has met eight of the nine requirements and all good practice recommendations made during the unannounced inspection on 24th February 2006. The home has purchased new carpets for the downstairs lounge and is awaiting new settees for the upstairs lounge. 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. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New prospective service users receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet the needs of new prospective residents. EVIDENCE: The inspector viewed two assessment documents during this inspection; new prospective residents are assessed in detail by the registered manager and or placement manger of the organisation. Both assessed files had a detailed assessment from social service in place. The assessment forms part of the care 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 9 plan. Residents informed the inspector of being involved in the assessment process. The inspector viewed the assessment policy, which has been reviewed in August 2006. One resident informed the inspector that he had a trial visit prior to moving in; this was clearly recorded in the service users care plan. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are of very good standard and service users involvement is evident throughout all care plans. Residents can choose where to go, what to eat and evidence of this was observed during this inspection. The home has detailed risk assessments in place and service users are involved in the review process. EVIDENCE: The inspector viewed two care plans during this inspection, both documents have been of very high standard. Care plans are reviewed twice per year, once 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 11 internally and once externally. The inspector viewed detailed records of these reviews. Additionally support plans are reviewed quarterly and key workers meet regularly with service users for one to one key worker meetings. Service users informed the inspector of being involved in these meetings and the inspector has viewed records of this. Care plans are very well structured and provide excellent information for new and existing staff. The registered manager informed the inspector that the organisation is currently in the process of changing their care planning processes and records, the inspector overheard the registered manager informing staff of providing a sample file for key workers to follow when setting up the new system. The inspector assessed financial records, which have been of good standard. Residents are able to make choices, which was observed during this visit. E.g. staff asked a resident not to scream if they are not happy with the activity, but tell staff if they want to do anything else. One service user informed the inspector of being able to go out whenever he wants and having choices about meals, his money, his medication, etc. The home has a range of detailed risk assessments in place, which have been reviewed and updated if necessary. Risk assessments are produced by a number of staff and service users are involved in the process. Reason why certain activities cannot be undertaken a clearly risk assessed and alternatives are offered if available and or suitable. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 13 Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. The home is supporting residents to live a full, culturally appropriate and stimulating life. Residents can choose where to go, what to do and what to eat and are involved in the planning of activities. EVIDENCE: Service users attend day services and in-house activities such as painting, table top activities,etc.are provided. None of the residents living at the home are in formal employment, but some residents do voluntary work through the day centre. Residents participate in numeracy and literacy groups in their day services; this however depends on their abilities. Residents access the community regularly; one resident is going to evening activities on most evenings. Residents informed the inspector that they go to discos, have dinners out and are happy the way the home supports around community based activities. The inspector observed residents leaving during this inspection to go to the bank or to do some personal shopping. The home has two MPV’s. Registrations with the electoral register have been viewed in service users files. One resident informed the inspector of meeting his girlfriend regularly and told the inspector that he could invite her to the home if he wishes. Families are involved and are invited to attend annual reviews. The inspector found in the compliments book very positive feedback about the home and the care provided. The home has a relationship policy. Residents have been observed locking their door independently and mail was given to service users unopened. Staff has been observed interacting with residents professionally and residents appeared to be comfortable with staff. Service users are encouraged to participate in activities but can choose if they want to do something different. The inspector observed residents accessing all areas of the home. Residents informed the inspector that they are responsible for the cleaning of their rooms, but staff would help them if they find some of the tasks difficult due to their disability. The home has clear guidelines about smoking, alcohol and drugs in place and risk assessments have been viewed where there is a risk to service users health. The inspector viewed the homes menu, which is varied healthy and of good standard. Staff does the cooking at the home, but service users can take part in the preparation of meals. The home is providing different diets for service 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 14 users with health issues. Regular temperature checks are undertaken and the most recent Environmental Health Officer visit was satisfactory. Residents informed the inspector that they could access the kitchen if they wish and specialist aids to maintain residents independence are available and have been purchased. Residents are involved in the menu planning and the registered manager is proposing to devise a picture menu to change the current practice of choosing meals in cookbooks. The fridge was stocked with food and drinks and fruit was available. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. Service users health is managed appropriately and residents are encouraged to be as self-managing as possible. EVIDENCE: The inspector observed staff supporting residents with poor vision, this was judged of being appropriate and the service users appeared to be comfortable with the support received. The home viewed clear personal care and manual handling guidelines in care plans. The inspector observed residents getting up 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 16 later during this inspection and staff informed the inspector that this particular service user enjoys having a lay in. Residents have detailed and clear personal care guidelines to ensure and maintain consistency. The guidelines are reviewed regularly. The home has purchased a special kettle for one resident to avoid scalding, but to enable the resident preparing a cup of tea independently. The home has a bath chair, which has been serviced. The home can access Brent Learning Disabilities Service for clinical support. The registered manager informed the inspector of having contacted SENSE as recommended and one resident is receiving large print literature through SENSE. The inspector viewed clear and detailed health records in files sampled during this key inspection. Residents receive regular input from the community optician, but dental services have been stopped due to PCT funding issues. The registered manager called a NHS dentist during this inspection hoping to register all service users. All residents are registered with their own GP and can be visited in private at the home. The inspector viewed two health action plans during this visit. Service users with communication difficulties have been referred to the local Speech and Language Team and a communication profile is in place. The home is using BOOTS Monitored Dosage System, records where of good standard and one deputy is responsible for the ordering of new medicines. The home has clear records of medication received and returned and no gaps where found on the Medication Administration Sheet. The home has arranged medication training for 24/01/07 and staff that have difficulties with the correct administration of medication have received extra support and training from the registered manager. The home is assessing staff every six months if they are still following correct procedures and a record of this was available for inspection. One of the residents living at the home is self-administering and correct procedures as well as detailed risk assessments are followed and are in place. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and self-harm. EVIDENCE: The inspector viewed complaints records; the home did not receive any complaints since the last inspection. Incidences are clearly recorded, followed up and resolved by the manager. The complaints policy is available in a userfriendly format and has been displayed throughout the home for easy access. The home is recording compliments and the inspector has noted positive responses from clinicians and visitors. The home has a Protection of Vulnerable Adults policy, which is compliant with National Minimum Standards. The home did not have any Protection of Vulnerable Adults allegations since the last inspection. Staff is informed during 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 18 their induction regarding Protection of Vulnerable Adults processes and during their Learning Disabilities Award Framework induction/foundation. The manager is currently organising formal Protection of Vulnerable Adults training for staff. The home was trying to obtain Protection of Vulnerable Adults guidelines from funding boroughs, which proved to be very difficult. The inspector recommends continuing obtaining Protection of Vulnerable Adults guidelines from any funding boroughs. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely nicely decorated environment, which is clean and free of any offensive odours. Service users are encouraged to bring their personal possessions. EVIDENCE: 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 20 The home is split into two flats, which are managed by one registered manager. The home looks very homely and comfortable. Tow service users invited the inspector to see their rooms, which were nicely decorated and service users personal possession was displayed. One room had pictures from the service users country of origin. The service of the bath chair in the ground floor bathroom has expired; the registered manager informed the inspector that the chair is not in use. The home was asked to remove the bath chair if not in use, which has been complied with during this inspection. The home has a maintenance programme in place, which is reviewed monthly. The home has two utility rooms, both had a washing machine and clothe dryer in place. The floors and walls are easy to clean and the COSSH cupboards have been locked. The inspector noted that the extractor fan in the downstairs utility room was very dirty and informed the home to clean the fan regularly to ensure the fan works within full capacity. The home has a range of Health and safety polices in place. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome is is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a diverse, experienced and skilled staff team. Appropriate recruitment policies and procedures protect residents from unsuitable staff. EVIDENCE: Records showed that the home is just above the required 50 of staff having National Vocational Qualification in Care training. The inspector informed the 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 22 registered manager to continue providing National Vocational Qualification in Care training to ensure that trained staff is always on duty. Staff spoken to are committed, enthusiastic and demonstrated excellent knowledge of service users needs. The staff team is working well together, which was confirmed by one member of staff who referred to the team as “fantastic”. The home does not employ any staff under the age of 18. The home has a good range of new and longstanding staff. The inspector informed the registered manager that if staff is in charge and has not reached the age of 21, she would need to do a risk assessment. The homes manager undertakes recruitment, staff informed the inspector of having to provide a Criminal Records Bureau checks, two references, etc and had a formal interview. The inspector viewed two staffing files during this inspection, which confirmed that the necessary checks are in place. The home has a detailed training programme in place; staff have a training and development plan, which has been updated regularly. The registered manager informed the inspector that staff can choose training from a list, which is displayed in the office and training needs are addressed in supervisions, staff confirmed this. Staff has an induction and have to do their Learning Disabilities Award Framework foundation within the first six months of employment. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 24 Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager is skilled and qualified to manage the home. Residents are regularly involved and consulted in the running of the home. Residents Health and Safety is not compromised and safe working practices are in place. EVIDENCE: The registered manager Mrs Nicky Bober is very experienced and has been working at the home since opening. Mrs Bober is registered with the Commission for Social Care Inspection and is currently in the process to complete her National Vocational Qualification in Care Level 4, she holds Assessor qualifications D32/33. Staff provided the inspector with very positive feedback and referred to the manager as supportive, fair but firm, helpful, etc. The home is arranging regular team-meetings for staff and an agenda was displayed on the notice board. The home is receiving quality assurance visits every six months and forwards Regulation 26 report to the Commission for Social Care Inspection monthly. The home achieved during the last internal audit 100 , which is commendable. The registered manager informed the inspector that service users surveys have been distributed in January and a letter will be send out to families enquiring how they feel service is provided by the home. The home has received very positive feedback previously, “SU looks better than I have ever seen him”, “we are very happy with care provided,” Contact with Kenton Road has always been positive.” The home has an updated fire risk assessment in place, fire points are checked weekly, emergency exits are checked weekly, emergency lights monthly and the home is undertaken six fire drills per year. All staff has attended fire training. The fire equipment has been checked, but the registered manager is not sure the name of the company, which should be recorded. The Landlords Gas Safety Certificate has been renewed during the day of this inspection, the Portable Appliances Test Certificate is valid until 17/07/07,the water system has been tested for Legionella on 20/10/05, the electrical installation has been checked, but the copy was very poor and the inspector asked the home to forward a copy to the Commission for Social Care Inspection. The Environmental Health Officer visited the home in October 2006 and all was judged as satisfactory. The home has a range of Health and Safety policies and procedures in place, which are reviewed in regular intervals. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 25 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 4 40 X 41 X 42 3 43 X 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 237 Kenton Road Score 3 4 4 X DS0000030898.V303337.R01.S.doc Version 5.2 Page 27 YES 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 YA24 Regulation 23(2) Requirement The ventilation fan located in The laundry facility needs regular cleaning. (The Timescale of 01/05/06 has expired) Timescale for action 10/02/07 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. 3. 4. Refer to Standard YA23 YA32 YA32 YA42 Good Practice Recommendations The home should try to obtain Protection of Vulnerable Adults guidelines from funding boroughs. The home should continue training staff to National Vocational Qualification in Care level 2 or above. If staff is in charge and younger than 21 the registered manager should do a risk assessment. The name of the company undertaken fire system services should be known to the home. DS0000030898.V303337.R01.S.doc Version 5.2 Page 28 237 Kenton Road 5. YA42 The home should obtain a clearer copy of the Electrical Installation Certificate and forward a copy to the Commission for Social Care Inspection. 237 Kenton Road DS0000030898.V303337.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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