Inspection on 24/02/06 for 237 Kenton Road

This inspection was carried out on 24th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

237 Kenton Road 16/01/07

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 Judith Brindle Unannounced Inspection 24th February 2006 08:30 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 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.V269513.R01.S.doc Version 5.1 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.V269513.R01.S.doc Version 5.1 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) 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.V269513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th September 2005 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. The care home is owned by Care Tech Community Service Limited. 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. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout 4 hours during a day in February 2006. There were two vacancies at the time of the inspection. The inspector was pleased to meet, and talk with the residents, and spoke with the care staff (and the maintenance person) that were on duty (on both units) during the unannounced inspection. A comment/feedback card from the Commission for Social Care Inspection in regard to the service provided was received from a relative. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The registered manager was on attending a training session away from the care home, but spoke briefly with the inspector via the telephone during the inspection. This inspection focussed on spending time talking with residents, and observing interaction between residents and staff. The communication and sensory needs of the residents (including verbal skills) are varied. Some of the resident’s use sounds, gestures and some words in response to verbal interaction. Assessment as to whether the requirements from the previous inspection had been met also took place during the inspection. Staff, and records confirmed that these had been almost all met by the service. Documentation inspected included, resident’s care plans, residents’ financial records, risk assessments, staff training records, and some policies and procedures. A tour of both units took place. 12 National Minimum Standards for adults were inspected (and 2 Standards partially assessed) during this inspection. These were all met or almost met. What the service does well: The home (both units) has a very welcoming atmosphere. The home enables, and supports residents to participate in varied in-house and community based activities of their choice that meet their individual needs. Staff have a good knowledge and understanding of residents varied and complex needs. Interaction between staff and residents was positive and respectful during the inspection. A resident spoke of being happy with the care received by the service. Feedback about the service provided from a relative was positive. Staff demonstrated competency, and motivation. They confirmed that communication, and support within the staff team was positive. The home has good access to a maintenance person. The home is very clean, light airy, well decorated and homely. The care home is responsive and pro-active in regards to reviewing and improving the service provided to residents by the care home. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 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.V269513.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The key standard 2 was assessed during the previous inspection in September 2005 and was judged as having been met. EVIDENCE: 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6, 7, and 9 Arrangements are in place to ensure that all the residents each have a plan of care, and support that meets their individual assessed needs. Arrangements are in place to support residents to make decisions (as far as they are able) about their lives. Residents receive assessment in regard to possible risks that they may encounter within, and outside the care home. EVIDENCE: All the residents have an individual plan of care. Two care plans from each unit were inspected. Each care plan recorded an individual profile of the resident, and their support requirements. Records informed the inspector that resident’s preferences, including food ‘likes and dislikes’ were recorded in their 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 10 care plan. Resident’s individual goals were recorded. There was recorded evidence that residents attend review meetings with staff and others in regard their progress in meeting their goals/needs. These varied needs and goals are reflected in the care plan records. Staff guidance to meet residents’ individual needs, including managing resident’s behaviour that might challenge the service was recorded in care plans. There was recorded evidence of risk assessment, which included bathing, kitchen risk assessment, and risk assessments in regard to behaviour from residents that might challenge the service. These recorded evidence of having been reviewed. Staff should record evidence that they have read the residents care plans. There was some evidence of this on the ground floor unit records, but these records should be updated. Records and staff confirmed that residents are enabled and supported to be involved in making choices (as far as they are able). Monthly resident meetings take place. Residents (particularly those who have no family/significant others contact and support) should if they wish find and participate in local independent advocacy services. Information about an advocacy service was accessible in the care home. Staff were observed to enable residents to make choices during the unannounced inspection. Residents are supported by staff to manage their finances. Two residents financial records and balances were inspected. These were up to date and fully recorded. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 13,15, and 16 Arrangements are in place to ensure that residents have the opportunity to participate in, and be part of the local community. Residents are supported, and enabled to maintain contact (if they wish) with family, friends and significant others. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 12 Resident’s rights are respected, and responsibilities recognised in their daily lives. EVIDENCE: Records, residents, and staff confirmed that residents have the opportunity to become part of the local community. The care home is close to a variety of amenities, which include, shops, banks, restaurants, and pubs. The care home has access to two passenger vehicles. Records, and staff informed the inspector that residents go shopping (one resident had plans to go with a staff member food shopping on the day of the inspection), they go to theatres, cinemas, bowling, attend college, go for walks, and attend church services. A staff member informed the inspector of the full involvement that two residents had with a local church congregation. A resident who kindly spoke with the inspector reported that she went out with staff to buy her toiletries. Several residents attended day resource centres, and others had a number of planned community based activities on the day of the unannounced inspection. A resident participated in a 1:1 craft session with a staff member during the unannounced inspection. A staff member confirmed that the residents were recorded on the electoral role. A staff member, records and a resident informed the inspector that residents contact with relatives, and significant others was supported and maintained. Staff gave examples of relatives participating in resident’s birthday celebrations, and of family members ‘popping in’ to see residents at varied times during the week. Staff spoke of visitors being welcomed in the care home. The visitors’ record book confirmed that there were numerous visitors to the home. There were records of positive comments about the service recorded by visitors. Residents preferred routines are recorded in the care plans. Staff were observed to respect the privacy, and dignity of residents, and knocked on resident’s bedroom doors, and on bathroom doors prior to entering. A staff member reported that residents have keys to their rooms, and that residents (if they are able) open their own mail. Resident’s preferred form of address is recorded in their care plans. Residents were given the choice during the inspection as to whether they wished to spend time alone. Staff spoke of residents regularly accessing the garden facilities in the summer months. Records, staff, and a resident confirmed that residents participated in household chores. A resident confirmed that confirmed that she was planning to tidy her room with staff support on the day of the inspection. A staff member reported that residents are also involved in their laundry duties, and in the preparation of some meals. The care home has a smoking policy. Staff informed the inspector that the home was a non smoking house. A record of a risk assessment in regard to passive smoking was available for inspection 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18 and 19. Arrangements are in place to ensure that residents receive personal support in the way that they prefer. Arrangements are in place to ensure that the health needs of residents are assessed and met. EVIDENCE: The care plans inspected recorded assessment of resident’s individual personal care needs. During the inspection resident’s privacy was respected. Staff spoke of the flexibility of times for getting up and going to bed, and that residents have ‘lie ins’ if they wish particularly at weekends. Staff guidance in regard to meeting personal care needs of individual residents was recorded in the care plans inspected. A resident confirmed that she chose her own clothes. Staff reported that residents go with staff to buy their own clothes. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 14 Records and staff confirmed that residents receive additional specialist support, and advice as needed by them. This includes occupational therapy and, physiotherapy support and assessment. Records confirmed that a resident had received a speech and language assessment. It is recommended that staff seek advice from specific organisations such as the Royal National Institute for the Blind (RNIB) in regard to support in meeting the sensory needs of residents within the care home. The inspector was informed that all the residents have a key worker. A resident who kindly spoke with the inspector knew who her key worker was, and was aware of the key workers’ role. Records confirmed that residents have their health care needs assessed. Care plans inspected included an individual resident’s health action plan. Residents receive care, and treatment from a GP, dental services, chiropody services, and optician services. Resident’s health needs are monitored, and staff guidance to meet individual health needs is recorded. Resident’s weight is monitored. A previous medication requirement in regard to the recording of resident’s known allergies on the medication administration record sheets was partially met. The record sheets located on the ground floor unit recorded known allergies, but this was not recorded on the sample of medication administration record sheets located on the first floor unit. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 (partially) 23 The accessibility of the complaints procedure in regard to relatives/significant others should be reviewed. Arrangements are in place to ensure that residents are protected from abuse, neglect and self-harm. Review of the service protection of vulnerable adults procedure is needed. EVIDENCE: Feedback from a visitor informed the inspector that they were unaware of how to access the complaints procedure. All relatives/significant others should know how and where to access the complaints procedure. The Local Authority protection of vulnerable adults procedure was accessible in the care home. An adult protection flow chart was displayed in the ground floor unit office. The care home’s ‘managing abuse’ policy was available for inspection. This procedure needs to be reviewed to ensure that there is clarity in regards to the procedure to be followed by staff in response to suspicion or allegation of abuse. It records that following receipt of a complaint of abuse, ‘report to the service manager who will then commence their own investigation’ or delegate this. Also the procedure records that the police are to be involved ‘if serious enough’ (it should be clearly recorded that the police need to be informed if there is evidence that a crime has been committed), also it records that the service manager will inform ‘where appropriate’ the 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 16 ‘Commission for Social Care Inspection, and social services care manager that an investigation is being carried out’. The registered person needs to ensure that the care home abuse procedure links with the Local Authority protection of vulnerable adults reporting guidance, and that the Local Authority is informed immediately. The Commission for Social Care Inspection must always be informed without delay when there is an allegation of abuse. The protection of vulnerable adult abuse policy needs to be accessible on the first floor unit. Staff reported that they had received protection of vulnerable adults training. Staff who spoke with the inspector had knowledge and understanding of reporting procedures in regard to suspicion and/or allegation of abuse. Staff guidance in regard to behaviour that might challenge the service was recorded in resident’s care plans. The home has a whistle blowing, and race awareness policies and procedures. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 The residents live in a homely, comfortable environment. EVIDENCE: A tour of the care home, (which included both units) took place during the unannounced inspection. Both units were very clean, light and airy, well decorated, and homely. The maintenance person reported that he had decorated the ground floor hallway the day before the unannounced inspection. A resident spoke of being happy with her room, and kindly showed 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 18 the inspector her bedroom. It was individually personalised, and had furnishings of quality. A previous inspection requirement in regards to a gas meter needing to be covered needs to be met. The dishwasher in the first floor unit was broken. Staff reported that a new one has been ordered. The laundry clothes dryer was making a significant noise. The registered person needs to ensure that the broken dishwasher is repaired or replaced, and that a competent person checks the dryer as to whether it needs repair. The laundry facility in the first floor unit is small and judged to be very warm. Staff reported that the laundry facilities are used frequently everyday. It is recommended that the registered person seek from a statutory authority i.e. environmental health in regard to ventilation advice. A review of the ventilation system in the laundry facility was recommended from the previous inspection. The ventilation fan located in this laundry facility needs cleaning. It was evident that hairline cracks in the ceiling of some resident’s rooms had been repaired, but there were some slight cracks still apparent in some bedrooms, and a ground floor shower room. These need repair. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 35 Arrangements are in place to ensure that staff receive appropriate training to be competent to meet resident’s varied needs. EVIDENCE: Staff reported that they were attending health and safety training on the day of the inspection. Records confirmed that a trainer had recently visited the home. Staff confirmed that they received varied and appropriate statutory training, and training to meet specialist needs. Staff reported that they received a comprehensive induction programme. A completed staff induction booklet was available for inspection. This was inclusive of appropriate information and training, and recorded evidence that management staff had assessed it. Staff reported that completed induction records are sent to an assessor for validation. Agency staff also receive an induction programme. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 20 Staff reported that most staff were in the process of completing or had already completed NVQ 2 in care training courses, and spoke of the course being useful in developing their knowledge and skills. This is positive for the service. An equal opportunities policy was available for inspection. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 39 and 42 (partially inspected) Arrangements are in place to monitor, and continue to improve the quality of the service provided to residents. The health and safety of residents is promoted and protected. EVIDENCE: 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 22 Records informed the inspector that there were monitoring systems in place in regards to quality of the service provided by the care home. Monitoring of care plans, staff training needs, and policies and procedures was evident. A comprehensive review of the service (including both units) took place in October 2005. Staff reported that questionnaires in regard to views of the service were sent to relatives/significant others, and supplied to residents. Commission for Social Care Inspection (CSCI) comment cards were located near the front door of the care home. Contact details of the Local Authority, and the CSCI were also easily accessible to visitors. Monthly proprietor visits to the home are carried out as required, and this information supplied to the CSCI. Feedback from a relative informed the inspector that they were not aware of how to access the CSCI inspection report. Relatives/significant others, and other visitors should be informed of how, and where to access this documentation. Records confirmed that numerous health and safety risk assessments had been completed, and were accessible. Staff were receiving health and safety training on the day of the unannounced inspection. There needs to be a risk assessment in regards to the use of portable fans and portable radiators in the care home. Bath thermometers were located in the bathrooms inspected. These were encrusted with lime scale, and the inspector was unable to view a water temperature reading clearly. These need to be replaced promptly. This was discussed with staff. COSHH (Control of Substances Hazardous to Health Regulations 1999) items were stored securely in the care home. The gas meter outside the upstairs floor must be covered. This was a previous requirement. The registered person needs to complete a risk assessment in regards to the gas meter until it is covered. There was an insurance certificate displayed in the 1st floor unit for a motor vehicle. This was dated September 2003. This should be archived. There were other certificates of motor insurance displayed in the ground floor unit, but these were not up to date. There needs to be recorded evidence of up to date motor insurance for the passenger vehicles. There is an up to date employer’s liability insurance certificate, which is displayed in the care home. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 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. 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 X 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 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 X 38 X 39 3 40 X 41 X 42 2 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 237 Kenton Road Score 3 3 2 X DS0000030898.V269513.R01.S.doc Version 5.1 Page 24 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 YA20 Regulation 13(2) Requirement Resident’s allergies must be recorded on the medication administration sheets (in the upstairs unit). Previous timescale partially met 15/10/05 • The registered person needs to ensure that the care home abuse procedure links with the Local Authority protection of vulnerable adults reporting guidance. • The Commission for Social Care Inspection must always be informed without delay (within 24 hours) when there is an allegation of abuse. • The protection of vulnerable adult abuse policy needs to be accessible on the first floor unit. The registered person needs to ensure that the broken dishwasher is repaired or replaced, and that a competent DS0000030898.V269513.R01.S.doc Timescale for action 01/05/06 2 YA23 12, 13(6) 01/05/06 3 YA24 23(2) 01/05/06 237 Kenton Road Version 5.1 Page 25 4 5 YA24 YA24 23(2) 23(2) 6 YA42 12,13(4) 23 12,13(4) 23 12,13(4) 7 8 YA42 YA42 9 YA42 13(4)(a) person checks the dryer as to whether it needs repair. The ventilation fan located in the laundry facility needs cleaning. Cracks in the plasterwork in ground floor bedrooms, and a ground floor bathroom need repair. There needs to be a risk assessment in regards to the use of portable fans and portable radiators in the care home. Bath thermometers need to be replaced. There needs to be recorded evidence of up to date motor insurance if the vehicle is to carry residents. • The gas meter outside the upstairs floor must be covered. Previous timescale 30/10/05 not met. • The registered person needs to complete a risk assessment in regards to the gas meter until it is covered. 01/05/06 01/07/06 01/05/06 15/04/06 01/05/06 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA7 Good Practice Recommendations Residents particularly those who have no family/significant others contact and support should if they wish find and participate in local independent advocacy services. • Staff should record evidence that they have read the resident’s care plans. It is recommended that staff seek advice from specific DS0000030898.V269513.R01.S.doc Version 5.1 Page 26 • 2 YA18 237 Kenton Road 3 4. 5 YA22 YA24 YA24 6 YA39 organisations such as the Royal National Institute for the Blind (RNIB) in regard to support in meeting the sensory needs of residents within the care home. All relatives/significant others should know how and where to access the complaints procedure. The carpet in downstairs lounge should be replaced (previous recommendation) • A stronger ventilation system for the utility room should be considered (a previous recommendation). • Recommend that the registered person seek advice from a statutory authority i.e. environmental health authority). Relatives/significant others, and other visitors should be informed of how and where to access the CSCI inspection report. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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. 237 Kenton Road DS0000030898.V269513.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!