Inspection on 25/05/07 for 3-5 High Worple

This inspection was carried out on 25th May 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3-5 High Worple 13/01/06

3-5 High Worple 22/07/05

3-5 High Worple 04/01/05

3-5 High Worple 02/06/04

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 3-5 High Worple Rayners Lane Harrow Middlesex HA2 9SJ Lead Inspector Judith Brindle Key Unannounced Inspection 25th May 2007 10:00 3-5 High Worple DS0000017539.V339856.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 3-5 High Worple DS0000017539.V339856.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. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3-5 High Worple Address Rayners Lane Harrow Middlesex HA2 9SJ 020 8866 2867 F/P 020 8866 2867 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) ASRA Greater London Housing Association Limited Ms Dina Devshi Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: 3-5 High Worple is a care home providing personal care and accommodation for up to 5 people who have learning disabilities. The home specializes in the care of Asian people from various cultural and religious backgrounds. There were no vacancies at the time of the inspection. The home is owned by ASRA Greater London Housing Association, which is a registered housing association, with charitable status. The organisations head office, based in SE1, provides senior management support to the staff and manager of the home. The home was opened in 1998. It is a two-storey building that was not originally used for residential care but has been suitably adapted. The home is located within a residential area of Rayners Lane, within the London Borough of Harrow. It is around the corner from shops, pubs, and public transport links including Rayners Lane tube station, and is close to a large park. The home has shared-driveway parking on each side. Parking restrictions apply on the road outside the home. All the homes bedrooms are single, fully furnished and with built-in sinks. The home has a bathroom, and two shower rooms, all of which have toilets. Access to the first floor is by stairs. The homes kitchen/diner and lounge afford it sufficient communal living space. The home has a reasonable-sized garden, with overlooking patio area that is easily accessible, and well maintained. The care home has accessible information about the service that it provides. Information about fees can be accessed from the owner of the home. The fees paid by people living in the home, are clearly documented in their care plan. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in May 2007. There were no vacancies at the time of the inspection. The inspector was pleased to meet and talk with the people living in the home, and with the staff on duty. The people living in the care home are all Asian. All of the residents understand English, and some speak it well. Comment cards about the service were received by the Commission for Social Care Inspection (CSCI) from all the people living in the care home. Four feedback questionnaires were also supplied to the Commission from relatives/significant others, and healthcare professionals. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The registered manager was present during the inspection. The responsible individual (the manager’s line manager) was present for part of the inspection. The inspection focussed on spending time talking with people living in the care home, and observing interaction between residents and staff. Documentation inspected included, resident’s care plans, residents’ financial records, risk assessments, staff training records, and some policies and procedures. A person living in the care home kindly gave the inspector a partial tour of the premises. Assessment as to whether the requirements from the previous inspection had been met also took place during the inspection. Staff and inspection of records confirmed that these had been met by the service. 25 National Minimum Standards for adults, including Key Standards, were inspected during this inspection. The inspector thanks all the people living in the care home, and the staff for their assistance in the inspection process. What the service does well: The care home has a very welcoming atmosphere. Residents live in a homely environment. People living in the home were positive about the care home and staff, and confirmed that they were happy living in the home. There is close liaison with healthcare professionals and other specialists as and when required/needed by the residents. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 6 People living in the care home are supported by staff to make life choices and to develop their independence, and to be empowered. Residents are fully involved in the care home, and participate in completing household duties including cooking and housework. Holidays for residents are a regular feature of the care home. Residents’ contact with relatives and others (as agreed by the residents) is fully supported and enabled by the care home. It was evident from talking to people living in the home, and from observation that they participate fully in their home, and are continually consulted and kept updated about the running of the home. A caring, well trained and competent staff team demonstrate knowledge, and understanding of the varied needs of people living in the care home. Staff have a good understanding of the religious and cultural needs of people living in the care home, and ensure that these needs are met. All staff speak a variety of Asian languages, which are spoken by people living in the care home. The registered manager is experienced, competent and well qualified. She is motivated and enthusiastic about her role and it was evident that she strives to continually improve the quality of the service for those living in the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. Arrangements are in place to ensure that prospective resident’s needs are comprehensively assessed prior to their admission to the care home. EVIDENCE: The statement of purpose and the service user guide documents include information about the service provided by the care home. The statement of purpose has been reviewed this year. These documents are recorded in written and picture format. The registered manager reported that the people living in the care home who can read, read English. Both documents include comprehensive information about the care home. Comment cards from people who use the service, received by the Commission for Social Care Inspection, confirmed that they had been supplied with information about the care home. The care home has an admissions procedure. There has been no admissions to the home for approximately two years. A care plan of one of the more recently admitted residents was inspected. This included evidence that prospective residents receive a comprehensive assessment of their needs before moving into the care home, and that this process of assessment 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 9 continues during the several varied visits to the care home (and during the admission trial period) by the prospective resident. Assessment information from the funding Local Authority and from healthcare professionals was also evident. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all residents have a plan of care, which confirm that they have control over their lives. The care plans celebrate the individual, their life experiences, and sets out in detail how people living in the care home have their current needs and aspirations met through positive individualised support. Residents are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. Risks are managed positively to help people using the service to lead the life that they want. EVIDENCE: All the people living in the care home have a plan of care. The care plan is developed with, and owned, by the individual. Each resident has signed a confidentiality statement, which gives their permission for some people to read their plan of care. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 11 Three care plans were inspected. These documents included an informative profile of each resident, and also comprehensive information in regard to assessment and in meeting resident’s personal care needs, health needs, activity/education and work needs, and religious and cultural needs. There is clear recorded guidance in regard to how these needs are to be met. Strengths and personal preferences are the focus of the care plans. These care plans recorded evidence of significant participation from each resident in the content of his or her plan of care. Each resident is central to their plan of care and participates fully in this plan, which includes signing documentation, such as key worker meetings, and review meetings records. The care plans record individual needs, goals, and reviews whether these goals have been met. Records confirmed that each resident has a support plan included in their plan of care, in which it was evident that resident’s views and feelings are sought, taken seriously and acted upon. Statements from the residents about their views of their care plan are recorded, and includes their aims/needs in regard to social and leisure preferences, religion/spirituality and cultural needs, finance, health, physical and emotional needs. The registered manager spoke of how care plans have been developed and are in the process of being further developed (including developing the format) into being even more ‘person centred. This is commendable. The care plans are up to date working tools used by the individual and all involved staff. Reviews of the care plans take place regularly, and become more frequent in response to changing needs of residents. Monthly reviews take place between the key worker and resident, and there are also six monthly reviews when residents have the opportunity to invite who they wish to the meetings, i.e. family members, care manager and significant others such as healthcare professionals. Residents spoke of making choices. These include shopping for clothes, toiletries, food, and choosing preferred activities. During the in section, staff were observed to consult with residents, negotiate with them, and to support them in making decisions. Residents have the opportunity to participate in regular resident meetings, and were observed to inform the manager and other staff about the content of a resident’s meeting that had taken place the previous evening. It was evident from speaking to residents, observation, and inspection of records that the care home promotes the empowerment of residents, and respect is at the forefront of the service provided by the care home. Some residents have an advocate. The inspector was informed that people living in the care home receive varying levels of support in regard to the management of their finances. Some residents manage their own money; others have relatives who manage the resident’s financial affairs. The registered manager reported that all the residents have their own bank account, and participate in the development of 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 12 their money skills, in managing their personal monies. There was recorded evidence of assessment of residents’ individual financial needs. Appropriate records of incoming and outgoing payments, and receipts are maintained. Records confirmed that people living in the home are supported and enabled to take responsible risks. The home has a comprehensive risk assessment protocol, with clear staff and resident guidance to meet these assessed needs. Staff ensure that residents have good information on which to base decisions, and that risk assessment is recorded in their plan of care. Risk assessments included administration of medication, shopping, cooking, finance, household chores, travelling on public transport, and in regard to behaviour from residents that might challenge the service. The home has a missing persons procedure. 3-5 High Worple DS0000017539.V339856.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): Standards 12,13,15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community. People living in the care home have the opportunity to take part in a variety of activities including those promoting personal development, independence, and being community based. Arrangements are in place to enable people living in the care home to maintain contact with family/significant others, as they wish. People living in the care home have their rights and cultural/religious needs respected and their responsibilities are recognised in their daily lives. Meals are chosen by people using the service, and are varied and wholesome, and meet the cultural and dietary needs of the residents. EVIDENCE: 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 14 Comment/feedback cards supplied to the Commission for Social Care Inspection (CSCI) from residents confirmed that they make decisions about what they want to do during the day, and at weekends. Records and residents confirmed that the views of people using the service have their views sought, and that their varied interests are considered when planning (with the resident) the routines of daily living and when arranging activities both in the home and the community. People living in the home kindly spoke to the inspector about the numerous preferred activities that they participated in. Residents and records confirmed that residents attend places of worship including church and Temple. A resident who showed the inspector the significant array of plants that had been grown by him. He spoke of ‘looking after’ the garden at the front of the house. On the day of the inspection, residents spent most of the day out participating in their leisure and employment pursuits. It was evident through observation and from talking to people who use the service that activities, plans and routines are resident focused, regularly reviewed and can promptly be changed to meet the needs and choices of each person living in the care home. During the inspection residents were observed to discuss and make a decision as to whether to attend an evening activity. Staff organised their shift duties to meet the choice made by the residents. It was evident that residents are supported in accessing employment opportunities, and that they actively seek information to enable people who use the service to access education and work. A resident works in a supermarket. The manager spoke of the ways that staff had (and continue to work with) worked with residents to gain and develop travel skills, to enable them to use public transport independently, or with minimal staff support. Residents spoke of ‘catching’ buses, and several accessed public transport during the inspection. It was evident from speaking to people using the service, records, and staff that the care home actively supports and promotes the residents to make informed choices, which includes developing and maintaining family and personal relationships. Residents spoke of having their own mobile telephone, and of the contacts that they had with friends and family/significant others. The care plans inspected clearly documented their social/leisure preferences and needs. Staff were observed to have understanding and respect for residents privacy. A resident used his own key to lock and unlock his bedroom door. Resident’s preferred form of address is documented in each care plan. People living in the home spoke of their involvement in household duties including cleaning their own rooms. The home has a large recently refurbished kitchen, with two cooking areas, one area is used for vegetarian cooking and the second is for non-vegetarian cooking. The home has a menu, which is agreed by residents, and displayed. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 15 The menu was judged to be varied, and wholesome. Changes are made to the menu in accordance with resident’s individual choice preferences. Residents spoke of enjoying the meals, and that they met their cultural/ethnic, religious and specific dietary needs. Several people living in the care home confirmed that they participated in shopping for food items of their choice. Two residents spoke of enjoying cooking, and one was observed to assist staff in cooking the evening meal. People living in the home were knowledgeable of healthy eating. A resident has recently won an award for their commitment to healthy eating. One resident spoke of having lost a significant amount of weight since living in the home, and of how that had led them to being more active, and happy. 3-5 High Worple DS0000017539.V339856.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): Standard 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s individual personal and healthcare needs are met. Medication is generally stored and administered safely, but there needs to be improvement in regard to aspects of medication administration. EVIDENCE: Care plans inspected recorded evidence that people who use the service receive effective personal, and healthcare support, according to their individual needs. Records, and from speaking to staff it was evident that staff are aware and knowledgeable in supporting residents to access healthcare. Records confirmed that people living in the care home have access to a GP, dentist, an optician and regular chiropody care and treatment. There was evidence of residents receiving specialist healthcare support, including occupational therapy assessment, diabetic monitoring via a specialist clinic, and psychiatric care, and support. Records confirmed that there was staff guidance to meet resident’s specialist healthcare needs, and that residents are encouraged to be fully involved in the management of their 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 17 healthcare needs, and their changing healthcare needs. Individual health action plans, with guidance were recorded in residents care plans. The care home has a medication policy including procedure and guidance in regard to the administration of medication. Medication storage and administration systems were inspected. Medication is stored securely. Records confirmed that a list of the signatures of the staff that administer medication is recorded. The care plans included assessment of their individual medication needs, and how these should be met. Medication administration records contained no gaps in recording. There were two instances when tablets had been dispensed from the incorrect day of the medication monitored dosage system. The manager reported that this was due to a resident (who is fully involved in their medication administration) who had by accident ‘popped’ out the medication from the medication administration system from the incorrect day. This needs to be recorded appropriately on the medication administration record sheet. Staff spoke of the medication training that they had received, and had an understanding of their role and responsibilities in regard to the administration of medication. 3-5 High Worple DS0000017539.V339856.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): Standard 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for ensuring that complaints are taken seriously and handled objectively. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints procedure. This has been recently reviewed, and is in pictorial/written format. A summary of this procedure is documented in the service user guide. When discussing with the manager about the possibility of the format of the complaints procedure being recorded in an Asian language, such as Gujarati, the manager reported that those residents who can read can read English, and that there the other residents cannot read in any language, hence the complaints procedure not being in another language format. This should be under on-going review. The complaints procedure includes clear records, timescales, and follow up actions taken by staff. There were three recorded complaints since 03/01/06. A person living in the care home spoke of speaking to staff if they had a concern or complaint. Recorded comment cards supplied to the Commission for Social Care Inspection confirmed that three residents were aware of how to make a complaint, but one recorded that they did not know the procedure. The manager spoke of ways that the home continues to ensure that all residents are aware of the complaints procedure. This action should continue. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 19 Records and residents confirmed that residents are encouraged and supported to communicate concerns about the service that they may have. A staff member was knowledgeable in understanding what action needs to be taken in response to complaints and or ‘concerns’ from residents and others. The home has a protection of vulnerable adults policy, and a whistle blowing policy. These were easily accessible to staff. Incidents are recorded as required. Staff have received training in safeguarding adults. A staff member had an understanding of the procedures to be followed when there is a suspicion or allegation of abuse. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 20 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): Standard 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely and comfortable. The premises are suitable for the care home’s stated purpose. Residents bedrooms are individually personalised, meet their individual needs. The care home is clean, and odour free. EVIDENCE: The inspection included a tour of the premises. The physical environment of the home provides for the individual requirements of the people who use the service. The home is clean, light and airy. It was evident from speaking to residents and through observation, that people living in the care home are supported and encouraged to see the home as their own. The home is well maintained. A new kitchen has been recently installed. The home has good access to local amenities and facilities. It is located a short 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 21 walk from Rayners Lane shopping area, and among its shops and restaurants are several amenities that meet the cultural needs of the residents. A resident spoke of buying local produce, which included his preferred Asian foods including spices. Public bus and train services are accessible close to the home. Residents spoke of ‘catching buses and trains’ regularly. People living in the home were observed to freely access all areas of the home. A resident kindly showed the inspector his room. He said he was very happy with his room. The room was individually personalised. Residents have their own key to their rooms. The home has an infection control policy/procedure. The laundry facilities are located away from food preparation and food storage areas. Residents and records confirmed that people living in the home participate in the care of their laundry. Records confirmed that staff had recently received infection control training. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 22 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): Standards 32,34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities. Arrangements are in place to ensure that residents are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: Staff were observed to interact with people living in the care home in a positive and respectful manner. Staff have varied cultural backgrounds and speak several languages including Asian languages as well as English. Staff and residents confirmed that staff have understanding and knowledge of the cultural, religious and language needs of the people living in the care home. People living in the care home spoke positively about the staff, and it was evident during the inspection that residents knew staff well and communicated with them freely. A resident spoke of the staff being ‘nice’. Comment cards from residents received by the CSCI recorded that staff treated them well, and that they listen and act on what people living in the home say. Records confirmed that the home has a staff code of conduct. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 23 The inspector ‘sat in’ on a staff meeting. It was evident that the staff attending that meeting were motivated, competent in their role as key workers, and were open to new ideas. It was evident that consistency in the way residents are supported by staff is a prominent aim/theme of the care home. The staff rota was accessible. This record informed the inspector that there were generally two to three staff on duty during the day and that there was a ‘sleep in’, and a waking night staff member on duty at night. The registered manager confirmed that staffing levels reflect the needs of the people using the service, and that staff rotas are flexible in order to meet the lifestyle of residents, and their changing needs. The care home has a recruitment and selection procedures. Staff records confirmed that these procedures are followed, and that that appropriate Criminal Record Bureau checks are carried out, to ensure that residents are protected. The manager spoke of residents being involved in the process of recruiting staff. This includes short-listing prospective staff and being part of the interview panel. Two staff (who had been employed for a few months in the care home) reported that they were in the process of completing a comprehensive induction programme. They spoke positively of the induction programme and reported that it included gaining knowledge and understanding of the care home’s policies and procedures, they confirmed that time was spent observing senior staff working with residents, and had also spent time reading care plans. The home has clear staff probation procedures, to ensure that appropriate competent staff become permanent staff members. Records and staff confirmed that staff have the opportunity to carry out varied training to ensure that they are competent in meeting all the resident’s needs. This training included moving and handling training, fire safety, protection of vulnerable adults training, 1st Aid, food and hygiene training and infection control training. Records informed the inspector that specialist training such as epilepsy training, ‘Person Centred Planning’, risk assessment training and an introduction in regards to ‘challenging behaviour’ also have taken place. Epilepsy training for staff was taking place during the inspection. The manager spoke of carrying out monthly ‘in house’ training for staff in regards to staff gaining knowledge of the care home’s policies and procedures. Staff spoke of their being ‘lots’ of appropriate training. Staff (apart from the two new staff) have completed relevant NVQ level 2 care qualifications, and are in the process of enrolling for NVQ level 3. Records confirmed that staff had an individual training development plan. It was evident that staff meetings included education/training for staff, carried out by the manager. Staff spoke of receiving regular staff supervision. Records of staff supervision and staff appraisals were available for inspection. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 24 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 25 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): Standards 37,39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management approach of the care home creates an open, positive and inclusive atmosphere. The registered manager is qualified, competent and experienced to run the care home. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 26 The registered manager has managed the care home for several years. She is qualified, experienced and competent to run the home and meet its stated purpose. She has a Social Care qualification and has recently completed a BSC Honours degree in Psychology and NVQ 4 in Management qualification. She spoke of undertaking periodic training to maintain and update her skills and knowledge. It was evident that the manager knows the people living in the care home very well. She was observed to consult with residents and communicate with them in a respectful, positive and sensitive manner. Records, staff, residents and observation during the inspection confirmed that the manager is very motivated and pro active in ensuring that people living in the care home are supported and enabled to be as independent as they are able, and to lead a fulfilling and positive lifestyle. Records, staff and residents confirmed that there are clear lines of accountability within the care home. People living in the care home spoke positively about the manager. It was evident from speaking to the manager that she communicates a clear sense of direction in ensuring that the care home provides a quality service, which is resident led. The care home has a quality assurance policy. Records (including policies and procedures and care plans), which were inspected confirmed that these are kept up to date and reviewed. Several polices are in written and picture format. ASRA completes a regular business plan. The manager confirmed that she seeks and welcomes information from residents, and that satisfaction surveys are annually supplied to residents to gain more feedback. Residents had kindly completed Commission for Social Care Inspection feedback/comment cards. Records, staff and people living in the home confirmed that the home acts upon results of consultation with people who use the service and their representatives. Minutes of regular resident meetings were available for inspection. These recorded evidence of feedback from residents. Residents were observed (with some staff support) to feedback minutes of their meeting to staff, and planned action to meet goals from that meeting was discussed and agreed. It was evident from records and from observation during the inspection that people living in the care home are continually consulted on how the service runs and are able to influence key decisions in the home, such as staff selection, the day to day life of the home, and its future development. The registered manager’s line manager was present at the staff meeting, taking place on the day of the inspection. He communicated with staff about residents needs and of issues relating to the owner of the care home (ASRA). It was evident that he had good knowledge and understanding of the care home and was fully involved in providing a quality service to people using the service. Certificates of worthiness in regard to the servicing of gas and electrical systems in the care home were up to date. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 27 Required fire safety checks are carried out. The home has a fire risk assessment, which has recently been reviewed. Fire drills are carried out regularly as required. The care home has a health and safety policy. Health and safety monitoring systems are in place. These include daily checks of fridge and freezer temperatures, room temperature checks, hot water temperature checks, and equipment checks. Systems are in place for staff and residents to communicate concerns in regard to health and safety issues. Health and safety is discussed in resident’s meetings. Guidance and house rules in regard to health and safety is documented in the service user guide. Systems are in place to ensure that accidents and incidents are responded too and reported appropriately. The certificate of employer’s liability insurance was displayed and up to date. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 3 X X 3 X 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 29 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2)(4) Requirement Medication administration changes, need to be recorded appropriately on the medication administration record sheet. Timescale for action 01/08/07 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 Refer to Standard YA22 Good Practice Recommendations The registered manager should continue to develop ways of ensuring that all residents are aware of the complaints procedure. 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 30 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 3-5 High Worple DS0000017539.V339856.R01.S.doc Version 5.2 Page 31 - 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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