Inspection on 16/05/07 for 36 Shooters Avenue

This inspection was carried out on 16th May 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

36 Shooters Avenue 15/07/08

36 Shooters Avenue 19/01/07

36 Shooters Avenue 25/10/05

36 Shooters Avenue 31/05/05

36 Shooters Avenue 07/01/05

36 Shooters Avenue 19/05/04

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 36 Shooters Avenue 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG Lead Inspector Judith Brindle Key Unannounced Inspection 16th May 2007 09:30 36 Shooters Avenue DS0000017578.V337575.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 36 Shooters Avenue DS0000017578.V337575.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. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 36 Shooters Avenue Address 36 Shooters Avenue Kenton, Harrow Middlesex HA3 9BG 020 8907 8270 020 8427 0458 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) Quality Family -Based Community Care Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No admissions until requirements met as per Notice dated 24th June 2005. That no more service users are admitted to the home, until such time as the registered person can demonstrate that requirements imposed on the home by the Commission for Social Care Inspection have been met or are being met satisfactorily as deemed by the Commission. Date of last inspection 19th January 2007 Brief Description of the Service: 36 Shooters Avenue is a care home providing personal care and accommodation for three people who have a learning disability. The home is owned and run by Quality Family-Based Community Care (QFBCC), a local private and independent care service provider. The home has 24-hour staffing, including one staff member sleeping-over at night. It has been operating since 2001. The home is located within a residential area of Kenton, part of the London Borough of Harrow. The home is close to local shops and bus links, whilst tube links are around twenty minutes’ walk away. Parking restrictions do not apply on the road outside the home. The home’s drive can accommodate two vehicles. The premises are an adapted two-storey building. Two of the bedrooms are on the first floor, with the other on the ground floor. All are single rooms, fully furnished, and with built-in wash basins. The home has one bathroom with adapted shower facility, and toilets on each floor. Access to the first floor is by the stairs only. The home has a kitchen, a lounge, and a large rear garden that is shared with the next-door care home, also operated by QFCC. Information about the service provided by the care home is accessible and comprehensive. Information about the fees is available from the owner of the home. 36 Shooters Avenue DS0000017578.V337575.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. This key inspection was undertaken by Judith Brindle (lead inspector), and Andreas Schwarz (regulation inspector). There were no vacancies at the time of the inspection. The inspectors were pleased to meet and talk with the people living in the home, and also with the staff on duty. 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 tour of the premises was included in this inspection. Assessment as to whether the requirements from the previous inspection, and from an inspection carried out by a Commission for Social Care Inspection pharmacist inspector (on the 2nd April 2007) had been met, also took place during the inspection. 25 National Minimum Standards for adults were inspected during this inspection. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The inspectors thank 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. People living in the care home who kindly spoke with the inspectors were generally positive about all aspects of living in the care home, and were happy with their bedrooms. People living in the care home spoke of the choices that they were supported in making. Residents participate in a variety of preferred activities and leisure pursuits. Staff have a good understanding of the varied needs (including sensory needs) of the people living in the care home. The care home provides a homely environment for residents. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. 36 Shooters Avenue DS0000017578.V337575.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 36 Shooters Avenue DS0000017578.V337575.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 assessed. EVIDENCE: The statement of purpose and the service user guide documents include information about the service provided by the care home. The service user guide includes some pictures as well as written format. Copies of this document were included in residents care plan files. The statement of purpose has recently been reviewed, and includes the address of the registered provider, which meets a requirement from the previous inspection. The care home has an admissions procedure/policy. Staff and the statement of purpose documentation, informed the inspectors that admissions are not made to the home until a full needs assessment has been undertaken. The people living in the care home moved into this home approximately two years ago, from another of the Organisations’ homes (which closed). A resident spoke of having visited this home before moving in. Care plans inspected recorded evidence that residents have had their needs assessed. A 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 9 resident who has sensory and communication needs was observed to move freely around the home without staff assistance. Staff spoke of ways in which this resident; with staff support had gradually become fully orientated in regards to the care home environment. Records, and staff confirmed that the care home was meeting this resident’s needs. Due to the sensory needs being a secondary need to the resident’s learning disability needs, and that it was evident that this person’s needs are being met, a requirement from the previous inspection has been removed. Persons living in the home had a recorded statement of terms and conditions in their care plan file. Fees charged (in regard to what the resident pays) are recorded in the service user guide. 36 Shooters Avenue DS0000017578.V337575.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): Standard 6,7 and 9 Quality in this outcome area is adequate. 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, with recorded personal goals, but some development in care plan records should be carried out to ensure that there is evidence that people living in the home participate as fully as possible in their plan of care. Residents are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. Staff should ensure that all documentation is dated. EVIDENCE: All the people living in the care home have a plan of care. The three care plans were inspected. The home has two files for each person one with care plan objectives, and goals and one with any other information relevant to the person. The care plans inspected included a comprehensive profile of the people living in the home, which included a description of their varied needs, such as cultural and religious needs, dietary needs, and social needs. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 11 The home is reviewing resident’s objectives regularly, but is holding care plan reviews annually the statement of purpose however states that a review is carried out every six months. This is required. Attendance of the annual review of the care plans included the person living in the care home, their relatives, care manager, and staff from the care home. Records confirmed that the person using the service has generally signed the care plan objectives, but the objective review forms were signed by staff but not by the resident. There should be recorded evidence that people living in the home are given the opportunity to participate in the review of their objectives. It wasn’t clear whether objectives were always carried out. The home records when ‘members’ (people using the service) are going in and out of the house with staff. A staff member reported that this is not always kept up to date, as sometimes residents and staff forget to sign it. There should be daily records maintained of resident’s daily progress to ensure that there is evidence that resident’s needs are being met. The care plan information included documented procedures for people living in the care home that might at times exhibit difficult behaviour. The format to improve accessibility of information of the care plan and evidence of it being a working document was discussed with a senior staff member. It is recommended that the manager provide a more condensed care plan file and archive information that is not needed or out of date, such as achieved care plan objectives. The senior staff member showed an inspector a format of a care plan that she was aiming to develop. There are procedures in place to ensure that people living in the care home are given their mail. The inspectors noted that people using the service have had some risks assessed these are generally basic, and could be developed. The objectives included some recorded risk associated with each objective, but the risk assessment were not always dated nor signed by the resident. Documentation such as risk assessment information should always be dated and include evidence that the resident is aware of this assessment and consents to it. The inspector viewed residents’ financial records, which have been of good standard, and are monitored by the manager on a monthly basis. The manager ensures that spending money is accessible to all people using the service. The manager is not acting as an appointee for the people using the service. People using the service informed the inspector that they have their own money and purchase their own clothes and toiletries 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 12 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): Standard 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the care home have the opportunity to take part in a variety of activities including those promoting personal development, 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 generally varied and wholesome, but there needs to be (with advice from a dietician) a review in regard to the provision of ready made frozen meals. EVIDENCE: 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 13 Prior to this inspection, the registered person supplied the Commission for Social Care Inspection a report in regard to activities participated in by people living in the care home. During the inspection, one person using the service left to go to college for the day. The two other people using the service stayed in the home as they had a day off from the day centre. One resident spoke of being happy doing what he wished to do on his day off. The manager informed the inspectors that they found an appropriate day resource service for one of the persons living at the home. Residents spoke of the varied activities and leisure pursuits that they enjoyed. These included listening to music, shopping and going to the library. People living in the home spoke of being involved in household duties, such as ironing, tidying their bedrooms, and washing dishes. People using the service informed the inspector that they have been to an annual holiday in Butlins this year. One of the people using the service is visually impaired and literature in Braille is provided for this person regularly. This resident was seen to be reading documentation in Braille during the inspection. During the inspection people using the service were been observed to move around the care home freely, and chose to be on his or her own, or to socialise with others. Care plan objectives are based on teaching new skills, i.e. how to put in a DVD into a DVD player. Records showed that this is done monthly, which is judged as not being enough time spent on developing skills and more regular support needs to be provided, and documented. One person using the service informed the inspector that he has regular contact with his family, and the visitors’ book confirmed that relatives and/or significant others are visiting the home regularly. People using the service have the opportunity of meeting people in day centres and in colleges. Residents spoke of telephoning relatives on a regular basis. Prior to the inspection the registered person supplied the Commission for Social Care Inspection a report concerning the food and drink supplied to people living in the care home. The inspectors examined the contents of the freezer, and noted that a lot of ready-made meals were stored. Staff informed the inspector that approximately three times a week, people living in the home had a choice of these frozen ready meals for their dinner. People using the service informed the inspector that they would prefer cooked food. People using the service informed the inspector that they enjoy cooking and are happy to help preparing meals. The registered person needs to review the provision of these ‘ready made’ meals with the people living in the home, and look into reducing the number of ready-made meals provided to residents to possibly one meal per week. Up to date menus were not available which made it very difficult to judge if people using the service receive a nutritional well balanced diet. A senior staff member reported that it is a rolling menu and is flexible so that 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 14 resident’s choices can be accommodated on a daily basis. A resident spoke of regularly having meals that meet their cultural needs. A freshly cooked lunch was provided to residents during the inspection and was judged to be wholesome. A person living in the home spoke of enjoying this lunch. There was some recorded evidence that residents could choose a preferred meal. Food eaten by residents needs to be fully recorded. The home needs to have an up to date menu, and advice be sought from a dietician in regard to providing a nutritious meals to people living in the home. Fresh fruit was accessible to people living in the home. A resident was seen to help herself to some apples during the inspection. Records confirmed that residents weight is closely monitored. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 15 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 personal and healthcare needs are met. Medication is stored and administered safely. EVIDENCE: Records, and people living in the care home confirmed that residents’ personal care and health needs are assessed, and that these needs were being met. Records confirmed that there was some guidance in regard to resident’s morning and evening routines. Residents spoke attending healthcare appointments, which included visits to the GP, community nurse, optician and chiropodist. Assessment and advice from healthcare specialists including an occupational therapist was recorded. A resident spoke of having attended hospital appointments. Prior to this inspection, the registered person supplied the Commission for Social Care Inspection with details of an investigation carried out by her in regard to the administration and recording of medication. This was in response to requirements from the recent pharmacist inspection. The 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 16 inspector viewed the homes medication procedure, which is compliant with National Minimum Standards. All medication administration record sheets were in order and did not have any gaps. Records are maintained of disposal of medication. Staff had received medication training from the pharmacist during the week prior to the inspection. Records confirmed that staff receive an ‘in house’ assessment of their competency prior to administrating medication. The home obtained a returns book, and has started to record when medication is returned to the pharmacist. The inspector viewed risk assessments to assess if people using the service are able to administer medication independently. A senior staff member reported that she is monitoring the administration of medication procedure carried out by staff. Previous inspection requirements made following an inspection by the pharmacist inspector (2nd April 2007) were judged to have been met. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 17 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 policy, which includes timescales and recording procedures. This document is now accessible in Braille. The policy includes appropriate recording procedures. There were no complaints recorded. The registered person should seek ways of demonstrating that ‘concerns’ and complaints by residents are welcomed by the care home. The home had updated their Protection of Vulnerable Adults policy on 05/04/07. This now compliant with National Minimum Standards, and records how allegations of abuse are to be reported. Records and staff confirmed that staff have attended Protection of Vulnerable Adults training and demonstrated a good understanding of reporting allegations of abuse. It was evident that staff were knowledgeable of appropriate reporting and recording procedures. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 18 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 adequate. 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, but areas of the environment need to be cleaned, and there are some maintenance issues that need to be attended to. Residents bedrooms are individually personalised, and meet their individual needs. EVIDENCE: 36 Shooters Avenue is a detached property in Kenton. There is parking available for two vehicles. The outside parking space had a skip and rubbish bins. The entrance to the property appeared untidy from the remnants of building work and flowerbeds on the forecourt contained numerous weeds. The registered person should endeavour to improve the appearance of the forecourt area of the home. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 19 There is a large garden (shared by the next door care home owned by the provider) with raised vegetable beds. Staff spoke of plans to start planting vegetables and other plants with residents, now that the building work has been generally completed. The rear garden fence has been replaced with new fencing. The home has undertaken building work, which included refurbishing the conservatory. This allows people using the service having their meals in a pleasant, light and airy environment. The inspectors noted that in some of the utility areas, the building work has not been completed. This needs to be carried out. Care staff carry out the cleaning in the care home. The dining area and sitting room was found to be not clean in some areas. There was dried food (from the previous evening meal) on the dining table, breadcrumbs and other food on the floor, and the sliding doors could have been cleaner. A cleaning mop was located in the dining area. This was removed during the inspection. The stair carpet needs cleaning. This was discussed in detail with the senior staff member. Refurbishment of the kitchen has also been carried out. This could have been cleaner, and must be fully cleaned, including the microwave. The senior staff member spoke of being in the process of contracting a professional cleaning company to fully clean the home. She agreed to inform the Commission for Social Care Inspection when this had been carried out. It is recommended that the registered person reviews the cleaning arrangements in the care home, to ensure that the care home is clean at all times. The lounge is spacious; the inspectors noted however that some of the edging around fireplace is missing. The lampshade on the right hand side of the fireplace is broken and there are drill holes above the door leading to the patio. There are areas of the building work that need finishing off. The senior staff member/deputy manager spoke of this work being finished within the next few days. The top of the stair carpet is loose and could be a trip hazard. The deputy manager spoke of putting appropriate tape on to secure it. A resident kindly showed the inspectors his bedroom. It was individually personalised. He spoke of liking his room. Residents and staff confirmed that all the people living in the care home are provided with a lockable space for their personal valuables. It is recommended that a facility that is secured to the wall or a cupboard rather than a ‘cash tin’ facility be provided to residents if they wish. The home has infection control and Health and Safety policies in place. Laundry facilities are located away from food storage and food preparation areas. The washing machine has the facility to wash clothes at high temperatures. Suitable hand washing facilities are located throughout the home. Soap and paper towels were accessible to people living in the home, 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 20 staff and visitors. At the time of the inspection, the care home was free from any unpleasant odours. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32,34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive training and supervision 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 spoke of their experience of supporting and caring for residents with a learning disability, and were judged to have a good understanding and knowledge of the needs of people living in the home. Records confirmed this. People living in the care home spoke positively about the staff. Staff were observed to be respectful to residents. The inspectors observed staff interacting in a sensitive manner with people using the service. Records confirmed that staff had signed when they had read policies and procedures. The inspector inspected up to date staff rotas and judged the staffing as sufficient. On the day of the inspection this was confirmed. Staff spoke of 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 22 there being some flexibility in staffing numbers to ensure that the needs of people living in the care home are being met. Staff meetings take place regularly. Two members of staff have completed their National Vocational Qualification in Care (NVQ). A staff member spoke of having achieved a NVQ level 3 in care. The inspectors informed the manager that the home needs to continue to ensure that all staff have the opportunity to attain this qualification so that the home achieves the National Minimum Standard that 50 of care staff have this qualification in care. The home does not employ staff under the age of 18. The service has a recruitment procedure that clearly defines the process to be followed when employing staff. Records confirmed that this procedure is followed by the service. It was evident that the service recognises the importance of effective recruitment procedures in the delivery of a quality service, and for the protection of individuals. The inspector viewed all staffing records. Records assessed contained required information and documentation such as Criminal Records Bureau checks. Prior to this inspection, the registered person had supplied the Commission for Social Care Inspection with a record of staff training undertaken since the previous unannounced inspection. Staff who spoke with the inspector confirmed that they had received a variety of training appropriate for their job role and responsibilities. Records confirmed that staff have an individual personal development plan, which indicates their training needs. The home ensured that staff have received mandatory training such as Protection of Vulnerable Adults, First Aid, Food Hygiene, Health and Safety Medication and Challenging Behaviour Training. The inspectors noted that this is an achievement since the last inspection, but the home must ensure that all staff receives Manual Handling training as required in the Statutory Notice dated 7th November 2006. The senior staff member had an awareness that there are some gaps in the training programme, and spoke of the plans to ensure that this training is provided to all staff. She showed the inspector a training plan and staff training certificates. The home is providing new staff with an induction programme, and induction records were inspected. A staff member spoke of having completed an induction programme at the start of their employment. Staff who spoke with the lead inspector confirmed that they had received regular 1-1 staff supervision, and that this included a review of the staff member’s progress, and of residents’ progress and their needs. Records confirmed this. The inspector found that some of the staff supervisions had not taken place regularly. The senior staff member spoke of the reasons for this. The manager should record when and why supervisions have been cancelled. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care home needs a registered manager. Some arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place, but these need to be further developed. 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: Mrs Lorna Fox (acting manager and registered person), with support from a senior staff member manages the care home. There needs to a manager who is registered with the Commission for Social Care Inspection. The acting manager is a qualified nurse and social worker and has recently completed postgraduate studies in management; all this is recorded in the 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 24 homes Statement of Purpose. The employer’s liability insurance certificate is displayed and current. The home has a quality assurance folder, which looks at objectives in how the service can be improved. There was some evidence of required monitoring of systems in the home. These included reviewing documentation such as care plans, and carrying out staff training, and staff supervision. The senior staff member showed the inspectors a format of a stakeholder (relatives/significant others, health and social care professionals) questionnaire was shown to the inspectors. The staff member spoke of plans to supply these to people living in the care home, relatives, and others. People using the service have fortnightly members meetings; staff meet approximately every two months. Records showed that in both of these meetings the service and the resident’s needs are discussed. The Commission for Social Care Inspection received a copy of a visit made by the owner in March 2007. Previous inspections required that there is a provider’s visit to monitor the service provided by the care home every month, and that this be recorded. This requirement is judged by the inspectors as not being required anymore, particularly due to the current situation of the owner of the care home being presently the manager of it. Several documents inspected were not dated and/or not fully completed. Arrangements should be in place to ensure that all staff are competent at recording, and that records are maintained as required. Records confirmed that the electrical and the gas systems in the care home had received required checks. Fridge and freezer temperatures are monitored. Health and safety checks of the premises are also regularly carried out. A check by an Environmental Health Officer on 23/03/07 reported that standards are generally good. In regard to a previous inspection requirement, the registered provider supplied the Commission for Social care Inspection with a written report confirming that plumbing arrangements in the care home comply with water supply (water fittings) Regulations 1999. The home has fire safety procedures and an emergency plan. A recently reviewed fire risk assessment is in place. Required fire safety checks are carried out. The fire door leading to the hallway was wedged open, the inspector informed the manager to consult the fire authority and seek advice about appropriate opening and closing mechanisms for fire doors, and to ensure that if doors in the care home need to be left open during the day, that this be recorded in the fire risk assessment, and that the doors are closed at night. It is recommended that fire safety be discussed in team meetings and ‘members’ meetings. This was discussed with the deputy manager. Records confirmed that a copy of financial accounts in regard to the service had been supplied to the Commission for Social Care inspection. 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 25 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 2 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X 36 Shooters Avenue DS0000017578.V337575.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(2)(b) Requirement The manager must ensure that all care plans are reviewed six monthly as stated in the homes’ Statement of Purpose, to ensure that it is evident that the care home is comprehensively reviewing the needs of people living in the care home. • Food eaten by people living in the home needs to be fully recorded to ensure that there is evidence that residents are eating a nutritional diet. Advice needs to be sought from a dietician particularly in regard to the provision of ‘ready made’ frozen meals. The broken lampshade in the lounge must be replaced. • The drill holes above the sliding doors must be filled and repainted. • The registered person must ensure that the wooden border on the floor in the lounge is DS0000017578.V337575.R01.S.doc Timescale for action 15/07/07 2 YA17 16(2)(i) Schedule 4(13) 15/06/07 3 YA17 16(2)(i) 15/06/07 4 5 YA24 YA24 23(2)(b) 23(2)(b) 01/07/07 01/07/07 36 Shooters Avenue Version 5.2 Page 27 6 7 YA24 YA30 8 YA35 9 YA37 10 YA39 repaired. • The building work in the utility room must be completed. 13(4) 23(2) The top of the stair carpet is loose and could be a trip hazard. 23(2)(d) • The registered person must ensure that all areas of the home are cleaned and that this is maintained to a good standard. • The registered person must forward evidence to the inspector when professional cleaning of the home has been completed. 18(1)(c)(i) All staff must receive up to date manual handling training to ensure that staff and people using the service are safe (part of the Statutory Notice dated 7th November 2006). 8 Care The Registered Person must Standards Act appoint a manager, and part II (11) submit to the CSCI for registration, the name of that person so that they may become the Registered Manager. Previous timescales 01/03/07 not met. 24 (3) A system of regular reviewing, and improving, the quality of care provided at the home, including through consultation with service users and their representatives, must be set up. Reports of such reviews must then be supplied to service users and their representatives, and the CSCI. THIS IS RESTATED AS PREVIOUS TIMESCALE OF 01/09/03 and DS0000017578.V337575.R01.S.doc 01/07/07 01/07/07 01/07/07 01/09/07 01/08/07 36 Shooters Avenue Version 5.2 Page 28 11 YA42 13(4) 23(4)(a) 01/05/07 HAS NOT BEEN MET. • The registered person 01/07/07 needs to seek advice from the London Fire and Emergency Planning Authority regarding appropriate opening and closing mechanisms for fire doors, which allow doors to be open during the day. • The fire risk assessment needs to include a risk assessment in regard to doors in the care home being kept open during the day, to ensure that residents are not at risk. 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 YA6 Good Practice Recommendations It is recommended that the manager provide a more condensed care plan file and archive information that is not needed or out of date, such as achieved care plan objectives. There should be evidence that people living in the home are given the opportunity to participate in the review of their objectives. There should be daily records maintained of resident’s daily progress to ensure that there is evidence that resident’s needs are being met. Documentation such as risk assessment information should always be dated and include evidence that the resident is aware of this assessment and consents to it. It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. The manager must remove the weeds and rubbish in the area leading to the property. DS0000017578.V337575.R01.S.doc Version 5.2 Page 29 2 3 4 5 6 YA6 YA6 YA9 YA22 YA24 36 Shooters Avenue 7 8 9 10 YA26 YA30 YA36 YA42 It is recommended that a facility that is secured to the wall or a cupboard rather than a ‘cash tin’ facility be provided to residents if they wish. It is recommended that the registered person reviews the cleaning arrangements in the care home, to ensure that the care home is clean at all times. The manager should record when and why supervisions have been cancelled. It is recommended that fire safety be discussed in team meetings and ‘members’ meetings. 36 Shooters Avenue DS0000017578.V337575.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 36 Shooters Avenue DS0000017578.V337575.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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