Inspection on 08/05/07 for 385 Torbay Road

This inspection was carried out on 8th 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

385 Torbay Road 18/10/06

385 Torbay Road 10/01/06

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 Key Unannounced Inspection 8th and 10th May 2007 08:50 385 Torbay Road DS0000017564.V337642.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 385 Torbay Road DS0000017564.V337642.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. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 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) Santa Bapoo 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.V337642.R01.S.doc Version 5.2 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. 18th October 2006 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 who have a learning disability. Presently it is providing a service for Asian women with learning disabilities. 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 located on the ground floor. The home has an enclosed accessible maintained garden at the rear of the property. Documentation/information about the care home is accessible to residents and visitors. Information in regard to fees can be obtained by contacting the registered manager/provider. 385 Torbay Road DS0000017564.V337642.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 one and a half days 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 also with the staff on duty. The people living in the care home are all Asian women. All of the residents understand English, and some speak it well. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The registered manager was present during the second day 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 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 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 very positive about the care home and staff, and confirmed that they were all happy living in the home. People living in the care home are supported by staff to make life choices and to develop their independence. Residents are fully involved in the care home and participate in completing household duties including cooking and housework. Residents’ contact with relatives and others is fully supported and enabled by the care home. A caring, and competent staff team demonstrate knowledge, and understanding of the varied needs of people living in the care home. Staff 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 6 have a good understanding of the religious and cultural needs of people living in the care home, and ensure that these needs are met. Most staff speak a variety of Asian languages, which are spoken by people living in the care home. The registered manager/provider is experienced and she ensures that there is liaison with healthcare professionals and other specialists as and when required/needed by the residents. Holidays for residents are a regular feature of the care 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. 385 Torbay Road DS0000017564.V337642.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 385 Torbay Road DS0000017564.V337642.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. The format of these documents should be further developed. 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 statement of purpose has been reviewed in 2007. Copies of the service user guide documents were accessible in the care plan documentation of the four resident’s care plans that were inspected. The manager confirmed that all the people living in the care home have received a copy of the service user guide. The registered person should further develop (with participation from the people living in the care home) the format of these documents (particularly the service user guide) to improve the accessibility of the information to people living in the care home. The format could include pictorial and be documented in an Asian language spoken by people living in the home such as Gujarati. A senior staff member spoke of her plans (with people living in the care home) to develop the service user guide. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 9 The care home has an admission procedure. There has not been an admission to the care home for more than a year. The four care plans inspected (including the care plan of the most recently admitted resident) included assessment information in regard to resident’s needs. Records, staff, and people living in the care home confirmed that prospective residents are not admitted to the care home until a full needs assessment has been undertaken. The inspector was informed that the registered manager carries out the initial assessment, which includes involvement of the individual, generally, their family or representative. Records confirmed that an assessment from the funding authority care manager is also carried out. It was judged that a previous inspection requirement in regard to ensuring that there is evidence that an initial assessment of prospective resident’s needs had been carried out had been met. Care plans inspected recorded evidence of a terms and condition of contract. 385 Torbay Road DS0000017564.V337642.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. Risk assessments could be further developed to ensure that there is clear, recorded staff guidance to manage identified risk. EVIDENCE: All the care plans were inspected. Each care plan included a comprehensive profile of the person living in the care home, and recorded evidence of having been reviewed. The care plans recorded a number of needs, including culture and religious needs, community participation, leisure and social needs, with basic staff guidance to meet these needs. The care plans should be further 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 11 developed to ensure that it is evident that the people living in the care home are involved the planning of the care that affects their lifestyle and quality of life (‘person centred approach). The care plans should be easily understood and look into all areas of the individuals life, and should record timescales for action to be taken to achieve a goal/need, and there should be a recorded date for review for each goal/need. Resident’s daily progress records were fully recorded and included positive and comprehensive information about each person living in the home. People living in the care home confirmed that they had a key worker and spoke positively of their key worker. There should be the opportunity for people living in the home to have regular one to one recorded key worker meetings. Records confirmed that people living in the care home had the opportunity to attend weekly residents meetings, and that they participated fully in these meetings. A person living in the care home confirmed that she attended these meetings and that she enjoyed them. Residents spoke of making choices. These include shopping for clothes, toiletries and choosing preferred activities. Staff were observed to consult residents and to enable them to make choices during the inspection. Records confirmed that residents were recorded on the electoral register. The inspector was informed that all residents receive support in regard to the management of their finances. There was recorded evidence of assessment of individual financial needs. All the residents’ financial records and monies were inspected. Appropriate records of incoming and outgoing payments, and receipts are maintained. The balance of one person’s money was a few pence under what it should have been. This was discussed with a senior staff member. It is recommended that there is a system in place to provide evidence that the balance of resident’s monies are regularly (possibly daily) checked by staff. A resident who kindly spoke with the inspector had an awareness of their finances and spoke of saving for particular items that they wished to buy. Records confirmed that residents were informed of the amount that they needed to contribute towards their rent. The care home has a missing persons procedure. The care plans inspected included risk assessment, which included health and safety risk assessments, such as kitchen safety, and in regard talking to strangers. Some risk assessments should be further developed to ensure that there is always clear and comprehensive staff guidance to meet each resident’s individual risk assessments. This was discussed with staff. A senior staff member spoke of her plans to develop the risk assessments. 385 Torbay Road DS0000017564.V337642.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 varied and wholesome. EVIDENCE: People living in the care home spoke of the variety of activities including evening activities that they chose and enjoyed. These included ‘in house’ and community based activities. Several residents regularly attend day resource 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 13 centres during some weekdays, one of which is for Asian service users. A person living in the care home spoke of the voluntary employment that is regularly carried out by her. Residents were observed to participate in household duties during the inspection. These included helping to prepare lunch on the first day of the inspection. A resident spoke of enjoying shopping, and holidays. In 2006 several residents had been on holiday. They said that they had enjoyed this holiday. A resident spoke of being in the process of choosing a holiday for sometime later this year. Holiday brochures were accessible within the care home. During the inspection it was evident that routines are flexible, and that activities and plans are changed if residents wish. An Asian radio station was playing on the radio. When residents came home from their day’s activities they chose to watch an Asian programme on the television. A resident spoke of looking forward to her forthcoming birthday. She spoke of having enjoyed her birthday celebrations last year. A person living in the home spoke of regularly attending a Hindu Temple. Another resident has the opportunity to attend a mosque. Arrangements have been made in the care home to enable residents to practice their faith/religion. Residents spoke of being enabled to participate in regular prayers. Records, staff and residents confirmed that the diversity/cultural needs of residents were being met. Residents and staff confirmed that most staff speak the Asian languages, which are spoken by them. The care home has a visitors’ policy/procedure. Records confirmed that visiting times were flexible. The care home has a visitor’s recording book. Residents spoke of the contact that they had with family, friends and significant others. It was evident that family contact with residents is encouraged and supported (if agreed by the resident). Records confirmed that family members attended care plan review meetings. A resident spoke of the friends that she had within the community, and at the day resource centre that she attends. There is an accessible telephone, which residents can use. Staff were observed to respect resident’s privacy, during the inspection. People living in the care home were seen to choose when to be alone or in company, and made choices whether or not to participate in an activity. Residents were observed to freely access their own bedrooms and the communal areas of the care home. People living in the care home spoke of choosing meals on a weekly and/or daily basis, and of participating in the process of food preparation. Food eaten is recorded. The residents confirmed that meals provided meet their cultural needs, and preferences. A person living in the home was planning to help with the food shopping on the second day of the inspection. A person spoke of making her own packed lunch to take with her when attending a day resource centre. Another resident participated in the preparation of her own breakfast. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 14 A variety of dried, fresh and frozen foods were stored. This included an assortment of spices. Records, staff and people living in the care home confirmed that people living in the care home had knowledge and understanding of healthy eating, and are provided with well balanced meals. The residents have their weight monitored. 385 Torbay Road DS0000017564.V337642.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 adequate. 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 generally stored and administered safely, but there needs to be improvement in regard to aspects of medication administration, and staff medication training. EVIDENCE: Records confirmed that residents’ personal care and health needs are assessed, and that these needs were being met. A person living in the care home spoke of receiving the care that she needed from staff. Residents spoke of choosing their own clothes and of being involved in the purchase of items of clothing, and other personal items. It was evident that resident’s individual preferences in regard to clothes, hairstyle and (if applicable) make up were enabled and supported by staff. Records confirmed that people living in the care home have access to a GP, dentist, an optician and regular chiropody care and treatment. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 16 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. There was recorded evidence that changes in health needs were promptly identified at an early stage and that advice from the appropriate healthcare professional was sought. The home has a medication policy/procedure, which is comprehensive, but a copy of an old inadequate medication procedure dated 2004 was accessible on the first day of the inspection. The up to date medication procedure should to be accessible to staff at all times, to ensure that medication is administered safely to residents. Medication is stored securely. Staff and records confirmed that medication is checked weekly. There were no gaps in recording on the medication administration record sheets. Records confirmed that a resident had received a self medication risk assessment. A resident was prescribed some ‘PRN’ (medication to be given when needed) medication. General recorded ‘PRN’ guidance was developed by the registered manager following the first day of the inspection and was accessible on the second day of the inspection. Each resident must be prescribed individually his or her own PRN medication from the GP, and individual administration guidance recorded. Another resident had a hand written record of ‘PRN’ medication documented on their medication administration chart, and had received the pain killer (analgesia) medication twice. Staff informed the inspector that the tablets had been administered from the box of the other resident. This must not happen. Staff confirmed that this practice would cease immediately. Two other topical medications were being administered once a day when according to the medication administration label they were prescribed four times a day. The registered person must ensure that if there are changes in need in regard to medication that the GP is informed and an appropriate prescription by him or her is obtained. Staff confirmed that they would contact the GP promptly, and that this practice would cease. Staff spoke of having had medication training. The dispensing pharmacist had provided some training in regard to the monitored dosage system of administration of medication for staff in December 2006. The registered person needs to ensure that there is evidence that staff have received appropriate medication training in regard to the medication systems in the care home, which includes the principles behind all aspects of the home’s policy on the safe handling and recording of medication, to ensure that medication is administered safely to residents at all times. 385 Torbay Road DS0000017564.V337642.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 procedure. The complaints procedure should be accessible in Gujarati (or other preferred language) and possibly pictorial format to ensure its accessibility to all residents. There were no recorded complaints. It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. To provide evidence that all residents have knowledge of the complaints procedure and that the home welcomes residents communicating ‘concerns’ and complaints. This was a previous recommendation. On person living in the care home spoke of talking to staff if she had a concern or complaint, she confirmed that she felt that she would be listened to that it would be acted upon. The care home has appropriate policies and procedures in regard to responding to any suspicion or allegation of abuse. There is an accessible recorded whistle blowing and a counter bullying policy. Staff and records confirmed that staff had received appropriate training in regard to safeguarding adults. Records confirmed that abuse awareness is also part of the staff induction programme. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 18 The home has an old Local Authority safeguarding adult’s procedure, but should obtain a copy of the up to date Local Authority guidance in regard to safeguarding adults. This was a previous recommendation. A senior staff member reported that she had contacted the Local Authority to obtain a copy of this document. 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 19 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 home is a semi- detached house located in a quiet residential street in Rayners Lane, North Harrow. The home is in keeping with the other houses in the area. The home is close to a variety of amenities that include shops, restaurants, cafes and banks. Local transport facilities that include train and bus services and are within a few minutes walk from the home. The inspection included a tour of the premises. The home is generally well maintained and is very clean. During the unannounced inspection workmen 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 20 carried out the maintenance issues required following the previous inspection, and those that were identified during this inspection. This included installing new bathroom door locks, repairing broken tiles in some areas of the home including in the ground floor bathroom and laundry area, and securing a mirror, which was located in a resident’s bedroom. The registered manager spoke of her plans to improve the garden by purchasing a variety of flowering plants. Staff confirmed that the lawn was to be cut within a few days following the inspection. The décor of the upstairs bathroom could be improved. with the manager. This was discussed A resident kindly showed the inspector her bedroom. It included several personal items including ornaments and pictures, and the resident spoke of being very happy with her room. The home has an infection control procedure. The home was clean, bright and airy during the unannounced inspection. Laundry facilities are located away from food storage and food preparation areas. There was information displayed in the care home, which recorded appropriate procedures to minimise risk of infection. A food safety visit from the Environmental Health officer took place on 26/4/07. The registered manager spoke of how she had met or planned to meet the recommendations from this visit, including food safety monitoring checks. 385 Torbay Road DS0000017564.V337642.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 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: Many staff have worked in the care home for several years, and have considerable experience of supporting and caring for residents with a learning disability. The staff rota was inspected. There is generally one staff member on duty during the day. The manager completes some shifts in the home during the week, and is at other times accessible by staff for advice if needed. Most staff speak a variety of Asian languages including those spoken by the people living in the care home. Residents spoke positively of this. A staff member who could speak Gujarati was on duty during the inspection, and was observed to communicate with residents in that language as well as English. Staff who spoke to the inspector were judged to have good understanding of the varied needs of the residents, and interacted with them in a sensitive 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 22 manner. Records confirmed that staff have the opportunity to regularly attend staff/house meetings. Staff training records were inspected. Staff have an individual training and development plan. These recorded evidence that staff completed an induction programme. Training included manual handling, 1st Aid, breakaway training, health and safety training, protection of vulnerable adults training and food and hygiene training, and mental health training. A staff training and development plan was available for inspection. The registered manager confirmed that most staff had completed or were in the process of completing appropriate NVQ care training courses. A senior staff member spoke of being in the process of completing the Registered Managers Award and NVQ level 4 care course. The care home has a recruitment and selection policy/procedure. Three staff personnel records (a recorded checklist) were inspected. These contained evidence that appropriate recruitment and selection procedures are carried out, and that required documentation including an enhanced Criminal Record Bureau checks had been obtained. Staff spoke of receiving regular staff supervision. Staff supervision records were available for inspection, and confirmed that staff supervisions take place regularly. Records confirmed that a staff member had received an appraisal in 2006. 385 Torbay Road DS0000017564.V337642.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): Standard 37, 39 and 42 Quality in this outcome area is good. 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: 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 24 The registered manager/provider has many years experience of working with residents who have a learning disability, and has managed the care home for several years. It was evident that the manager knows the people living in the care home very well. She is also a trained nurse, and has completed a NVQ level 4 in management course. The registered manager reported that she regularly up dates her skills by undertaking periodic training. 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. The care home has a quality assurance policy/procedure. A business plan/annual report 2006/07 was available for inspection. There was also an audit and development plan in regard to the service that that had been completed. The manager reported that questionnaires about the service are sent to stakeholders (relatives/significant others, health and social care professionals) annually, and had been sent to them in 2007, but that none had as yet been returned. Documentation confirmed that records including care plans were kept up to date and reviewed. Certificates of worthiness in regard to servicing of electrical and gas safety systems in the care home were up to date. Records confirmed that regular health and safety checks are carried out, including fire safety checks. A fire risk assessment was available for inspection was last reviewed 16/03/06 and should be reviewed. A senior staff member confirmed that this was planned. Fire extinguishers and other fire safety equipment were serviced in March 06. The manager reported that there had been difficulties finding a competent person to service this equipment, but had now found an appropriate person that had planned to carry out these checks in June 2007. The manager agreed to supply the Commission for Social Care Inspection with documentation to confirm that these checks had taken place. Regular unannounced fire drills take place. The home has an accident reporting policy. Incidents are recorded appropriately. Fridge and freezer temperatures are monitored daily, and water temperatures are monitored on a weekly basis. The employers liability insurance is displayed and expires in January 2008. 385 Torbay Road DS0000017564.V337642.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 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X 385 Torbay Road DS0000017564.V337642.R01.S.doc Version 5.2 Page 26 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) • Requirement The registered person needs to ensure that there is evidence that staff have received appropriate medication training in regard to the medication systems in the care home, which includes the principles behind all aspects of the home’s policy on the safe handling and recording of medication. • There needs to be individual recorded staff guidance in regards to administering PRN (medication administered when needed) medication to people living in the care home. • Residents must be prescribed individually their own PRN (medication given when necessary) medication from the GP, and individual administration guidance be recorded. The registered person must DS0000017564.V337642.R01.S.doc Timescale for action 01/08/07 2 YA20 13(2) 01/07/07 3 YA20 13(2) 01/07/07 Page 27 385 Torbay Road Version 5.2 ensure that if there are changes in need in regard to medication that the GP is informed and an appropriate prescription by him or her is obtained. 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 YA1 Good Practice Recommendations The registered person should further develop (with participation from the people living in the care home) the format of the service user guide to improve the accessibility of this documentation to people living in the care home. The format could include pictures and be written in an Asian language spoken by people living in the home such as Gujarati. The care plans should be further developed to ensure that it is evident that the people living in the care home are involved the planning of the care that affects their lifestyle and quality of life (person centred approach). It is recommended that there is a system in place to provide evidence that the balance of resident’s monies are regularly (possibly daily) checked by staff. Some risk assessments should be further developed to ensure that there is always clear and comprehensive staff guidance to meet these individually risk assessed needs. The up to date medication procedure should be accessible to staff at all times, to ensure that medication is administered safely to residents at all times. • The complaints procedure should be accessible in Gujarati and pictorial format to ensure its accessibility to all residents. • It is recommended that the registered person develop systems to ensure that any residents ‘concerns’ are recorded and acted upon as required. The home should obtain a copy of the up to date Local Authority guidance in regard to safeguarding adults. The décor of the upstairs bathroom could be improved. The registered manager should meet the recommendations/requirements from the Environmental Health Officer visit. DS0000017564.V337642.R01.S.doc Version 5.2 Page 28 2 YA6 3 4 5 6 YA7 YA9 YA20 YA22 7 8 9 YA23 YA24 YA30 385 Torbay Road Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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