Inspection on 10/01/06 for 385 Torbay Road

This inspection was carried out on 10th January 2006.

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

Other inspections for this house

385 Torbay Road 08/05/07

385 Torbay Road 18/10/06

385 Torbay Road 16/08/05

385 Torbay Road 17/02/05

385 Torbay Road 05/08/04

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 18-65 385 Torbay Road 385 Torbay Road Harrow Middlesex HA2 9QB Lead Inspector Judith Brindle Unannounced Inspection 10th January 2006 09:00 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 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 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 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. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 385 Torbay Road Address 385 Torbay Road Harrow Middlesex HA2 9QB 020 8933 2625 01895 638 974 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) Ms Santa Bapoo Ms Santa Bapoo Care Home 4 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation agreed for one named individual VP aged 65 years for the duration of her stay. 16th August 2005 Date of last inspection Brief Description of the Service: 385 Torbay Road is a care home providing personal care and accommodation for up to 4 adults with a learning disability. The owner and registered manager is Ms Santa Bapoo. The home opened in 1996. It is located in a quiet residential street in North Harrow. The care home is within a few minutes walk from a variety of shops, restaurants, library, banks and other amenities. Public bus and train facilities are accessible close to the home. The home is a semi-detached house, which is in keeping with other houses in the locality. There is parking for 2-3 cars at the front of the house. All the homes bedrooms are single without en-suite facilities. There is one bedroom on the ground floor. The home has an enclosed accessible maintained garden. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place early morning, throughout two and a half hours during a day in January. There was one vacancy at the time of the inspection. The inspector was pleased to meet and talk with all the residents prior to them leaving the care home to attend their various day resource centres. The inspector also spoke with the staff member on duty. The staff member was very helpful during the inspection and supplied all documentation and information asked for by the inspector. The registered manager/provider spoke by telephone with the inspector during the inspection. The inspection focussed on spending most of the inspection talking with residents and observing their interaction with staff and with other residents. Also assessment as to whether requirements from the previous inspection had been met took place. Documentation inspected included, all the resident’s care plans, complaints and accident/incident records, the staff rota, and medication records. 16 National Minimum Standards for adults were inspected. Commission for Social Care Inspection feedback/comment cards for residents, and significant others to complete in regard to their views of the service, were given to the staff member, and a feedback card was given to a resident during the unannounced inspection. What the service does well: The care home has a very welcoming atmosphere. Residents are supported by staff to take part in a range of activities of their choosing, both in the care home and within the community. Residents are supported in maintaining relationships with their families and friends. Residents are supported by staff to make life choices and to develop their independence. Complaints recording indicated that residents’ concerns and complaints are listened to, and appropriate action taken by staff. Residents live in a homely environment. Resident’s bedrooms show varying degrees of personalisation. Residents are supported by a competent staff team who demonstrated knowledge, and understanding of the residents needs. All the residents are female and Asian. The care home is active in regard to understanding and meeting the cultural, language and religious needs of the residents. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 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. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 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 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 5 Arrangements are in place to ensure that residents receive a contract/statement of terms and conditions in regard to the service provided. EVIDENCE: All the care plans inspected recorded evidence of residents having signed a written contract/statement of terms and conditions. This documentation was also signed by the registered provider/manager. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6 and 9 Arrangements are in place to ensure that each resident has a plan of care developed from assessment of their individual needs. Arrangements are in place to ensure that risks to residents are identified, and that they are supported to take risks as part of an independent lifestyle. EVIDENCE: All three care plans were inspected. The documentation within the care plan format has continued to be developed and improved by the staff team. The information within the care plans inspected was accessible, clear and comprehensive. A staff member who had been employed within the care home within the last few months reported that the care plan format ensured that information in regard to meeting the resident’s needs was easily comprehensible and accessible. Each care plan included a comprehensive individual profile of the resident. There was also information, and staff guidance in regard to meeting the individual healthcare needs of the residents. This included, social needs, personal care needs, and medication needs of each resident. There was recorded evidence that these care plans were regularly reviewed, and that the residents and their relatives/significant others, such as the resident’s key worker, participated in the review process. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 10 There was recorded evidence that specialist medical/healthcare needs of residents were assessed, and that appropriate care and support provided. Progress records were available for inspection. These were comprehensive and positive in regard to recording resident’s needs, and actions during the day. Records confirmed that risk assessments are documented in the resident’s care plans. These include, finance risk assessments, bathing, accessing public transport, swimming, and cooking. These recorded evidence of having been reviewed regularly. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,14 and 15 Arrangements are in place to ensure that residents are supported in accessing employment opportunities, community facilities and participating in preferred activities. EVIDENCE: A resident kindly informed the inspector of the job in a charity shop that she had commenced. She spoke of the interview process and of the hours of work that she completed weekly. The resident spoke very positively of this job. All the residents were attending day resource centres on the day of the inspection. Two of the residents went to an Asian cultural day centre. The residents spoke of enjoying these facilities, and of having attended them for some time. The residents kindly described other activities that they participated in. These included cooking, shopping, needlework, and household chores, watching Asian films, and videos, and going to the library. The residents told the inspector about the holiday that they enjoyed last year, and of the various clubs that they attended and had attended. A resident spoke of the needlecraft hobbies that she enjoyed, and kindly showed the inspector examples of her work. All the residents spoke of the recent telephone contact that they had had with family and friends. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 12 A resident spoke of friends and acquaintances that she had at the day resource centre, and who she met at the clubs that she attends. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 and 20 Arrangements are in place to ensure that the healthcare needs of residents are met by the service provision. Medication is administered safely. EVIDENCE: Records and residents informed the inspector that the resident’s healthcare is monitored, and that they had access to care, and treatment by healthcare professionals. A resident kindly spoke about a recent optician appointment, and the glasses that she had received following that appointment. Care plans inspected confirmed that residents had access a GP, chiropody care, and dental services, and specialist healthcare services, which include psychiatric services. The weight of residents is monitored. The care home has a medication policy. Medication is stored securely. A staff member administered medication during the inspection in a sensitive and competent manner. There were no gaps in the medication administration records. The staff member on duty reported that she had received medication training. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 Arrangements are in place to ensure that the views and complaints from residents and others are listened to and that appropriate staff action is taken in response to these. EVIDENCE: The care home has a complaints policy/procedure. There have been no recorded complaints since the last inspection. The home has appropriate systems in place in regard to the recording of complaints. A resident spoke of informing her key worker if she had a concern/complaint. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24, 25 and 30 Residents live in a homely and safe environment. Resident’s bedrooms meet their needs and lifestyle. The care home is very clean EVIDENCE: The home is in keeping with other houses in the locality. The care home is within a few minutes walk from a variety of community amenities, which include, shops, restaurants, banks. Public train, and bus services are also close to the care home. There is an enclosed maintained garden at the rear of the property. A resident spoke of sitting out in the garden during the warmer months. The forecourt area at the front of the house was uneven in some areas. The registered person should review the condition of the surface of the forecourt area, and assess the risk to people walking on the area. A resident kindly showed the inspector around the care home. The home was warm, light and airy. Some communal and some bathroom areas of the home have been recently redecorated. Furnishings and fittings are of quality. The curtain rail in the ‘quiet’ sitting room area needs repair; it was on the floor of the room All the bedrooms are single rooms. Resident’s bedrooms were individually personalised, with pictures, ornaments and other items. A resident spoke of being happy with her bedroom, and she kindly showed the inspector her room. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 16 The premises is very clean, and free from offensive odours. Staff and residents complete household duties. Laundry facilities are located away from food storage and food preparation areas. The light switch cords in the bathrooms were not very clean, and one had the plastic ‘pull fixture’ missing. These cords should be replaced. The upstairs bathroom door did not close fully. This needs to be repaired. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32 A competent staff team supports the residents. EVIDENCE: The staff rota confirmed that there was generally one staff member on duty, and two staff on some occasions. There have been some new staff employed within the last few months; other staff members have worked in the care home for several years. Records and residents confirmed that staff were knowledgeable of the residents individual needs. A resident spoke of her key worker. The staff member on duty had been recently employed. She confirmed that she had completed a comprehensive induction programme, and that the staff team had been very supportive in assisting her with gaining knowledge and understanding of the individual resident’s needs. During the unannounced inspection the staff member on duty was observed to be approachable and interacted with residents in a respectful and positive manner. On occasions she spoke in Gujarati with the residents. Residents were positive about the staff team. One resident spoke of the staff being helpful and supportive. The registered manager reported that a staff member had almost completed a Foundation in Care induction course and that she would then commence NVQ level 2 care course, and that another staff member was in the process of completing an NVQ level 2 course. Also the manager informed the inspector that a senior staff member was in the process of completing a NVQ level 3 care course. Regular staff meetings take place. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 39 and 42 Some quality assurance monitoring systems need further development to ensure that there are effective systems in place to monitor the quality of the service, and to also continue to improve the service for residents. Arrangements are in place to ensure that the welfare, and health and safety needs of residents, staff and others are met by the service. EVIDENCE: There needs to be accessible information, and documentation in regard to quality assurance, which include effective monitoring, and review of systems in regard to the service provided by the care home, and which is based on seeking the views of residents. There needs to be a recorded annual development plan. This was a previous requirement. This was discussed with the registered manager/provider. She reported that there were plans for a review of the service, which would be completed by the end of March 2006. This needs to be actioned by the registered person. There was recorded evidence of monitoring some aspects of the care home. These included reviewing care plans, and monitoring health and safety aspects of the service. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 19 Records confirmed that residents have the opportunity to attend regular resident meetings, and that during these meetings the residents participated fully in communicating their views. A bathroom lighting fixture needs a lampshade or the fitting be changed due to the light bulb being exposed at present, which could be a health and safety risk. This was a previous requirement, and was discussed with the registered manager/provider during the inspection. Following the inspection the manager reported that she was in the process of ensuring that this was being attended to. There was recorded evidence that health and safety checks had been carried out. A health and safety check of the care home was recorded as having been carried out this month. The fire risk assessment was dated 25/7/04. This should be reviewed at least annually. Emergency guidance, and fire action guidance was displayed. There was also accessible recorded guidance in regard to food and hygiene safety. Portable electrical appliance checks had been carried out in June 2005. Accidents and incident records were available for inspection. There had been none recorded since the previous inspection. The employers liability insurance certificate was displayed and expires 21/1/06 The Commission for Social Care registration certificate was appropriately displayed. 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 385 Torbay Road Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000017564.V269716.R01.S.doc Version 5.0 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23(2) • Requirement The curtain rail in the ‘quiet’ sitting room area needs repair. • The upstairs bathroom door needs to be repaired. There needs to be a recorded annual development plan in regard to the service. Previous timescale 01/11/05 not met. The electric light fitting in the upstairs bathroom needs to be appropriately covered or replaced. Previous timescale 01/11/05 not met. Timescale for action 01/03/06 2. YA39 24(2) 01/04/06 3. YA42 13(4) 01/03/06 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. 2 Refer to Standard YA24 YA24 Good Practice Recommendations The bathroom light switch cords should be replaced. The registered person should review the condition of the surface of the forecourt area and assess the risk to people walking on the area. DS0000017564.V269716.R01.S.doc Version 5.0 Page 22 385 Torbay Road 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 385 Torbay Road DS0000017564.V269716.R01.S.doc Version 5.0 Page 23 - 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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