Inspection on 19/06/06 for 4 College Road

This inspection was carried out on 19th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

4 College Road 23/08/07

4 College Road 10/02/06

4 College Road 04/11/05

4 College Road 22/07/05

4 College Road 31/01/05

4 College Road 05/04/04

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 4 College Road Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL Lead Inspector Julie Schofield Key Unannounced Inspection 19th June 2006 08:20 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 4 College Road Address Striving For Independence Group 4 College Road Wembley Middlesex HA9 8RL 020 8908 6894 020 8900 9633 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) Striving For Independence Group Homes Mrs Dorothy Pinnock Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation agreed for one named individual (MH) aged 65 years for the duration of his stay, subject to regular reviews. 4th November 2005 Date of last inspection Brief Description of the Service: This home is one of a group of 3 homes, in Brent and in Harrow, which are owned by the proprietors company (SFI - Striving for Independence). This care home provides a service for 3 adults with learning disabilities. At the time of the inspection there were no vacancies. The house is semi-detached and the property consists of two floors. The service users bedrooms are situated on the first floor, with bathing and toilet facilities on both floors. There is an open plan dining area and lounge, kitchen and office (including sleeping in facility) situated on the ground floor. Patio doors lead from the dining area to the garden at the rear of the property. The proprietor is also the registered Care Manager. There is a close connection between the homes in the group and the company also runs a day care facility in Wembley. College Road is a quiet residential turning close to Preston Hill and within reach of both bus and underground rail services and local shops. Enquiries regarding fees charged for placements should be made to the manager of the home. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 visits to the home, as the registered manager had existing commitments during the afternoon of the first inspection day. The first visit commenced at 8.20 am on the 19th June 2006 and finished at 2.20 pm. The second visit commenced at 8.05 am on the 31st July 2006 and finished at 12.05pm. The Inspector would like to thank the manager and staff for their comments during the inspection visits and for the opportunity to meet the residents. As feedback from residents varied according to their verbal communication skills, the interaction between staff and residents and care practices were observed. In addition to discussions with the manager and with staff the inspection also included a site visit and examination of records. Some of the records were held at head office and were viewed there. Information regarding the fees charged may be obtained from the home, on request. What the service does well: The manager and staff continue to encourage residents to dress smartly and to take a pride in their personal appearance. There was a “family” atmosphere in the home with warmth between the manager and the residents and with residents helping each other. The member of staff on duty was attentive to the needs of the residents. The home is maintained to a good standard and each resident has a pleasant room, in which to relax. All areas of the home are furnished and decorated in a comfortable and “homely” manner. Residents also have access to spacious grounds at the back of the house. Residents have opportunities to lead an enjoyable and stimulating lifestyle, which takes into account their individual preferences and includes an annual holiday. They make good use of local facilities and the company arranges weekly outings with its own transport provided. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: 14 statutory requirements were identified during the inspection. Care plans need to include an identification of social and leisure needs. The time for going to bed must be of the resident’s choosing and records must not refer to the resident being sent to bed. Records kept must respect the dignity of the resident. Pre-printed medication records prepared by the company must be an accurate record of the dosage, number of tablets and time at which they are taken. Some minor repairs are needed in one of the resident’s bedrooms. The home is asked to notify the CSCI when the outstanding CRB has been returned and to forward a copy of the revised development plan for the home. The home must not accept “to whom it may concern” letters but request references from a named person or manager/proprietor of a business. The home needs to distribute the quality assurance questionnaires and use the feedback to inform the development plan. There must be a valid certificate for the electrical installation and for the fire alarms/emergency lighting. Training attendance or completion certificates must be kept on file with the staff member’s training profile. All staff must complete first aid training. Individual supervision sessions need to take place at least every 2 months and a record kept of the content of the meeting. The programme of overdue annual appraisals must be completed. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 7 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. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 8 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 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 9 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 2 was not inspected as each of the residents has lived in the home for approximately 10 years. EVIDENCE: 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the resident are identified and addressed in the care plan and this must include social and leisure needs. Regular reviews of the care plan and placement determine whether the care home continues to be able to meet the individual needs of the resident. Offering a resident choice encourages and supports the resident to develop their independent living skills. Staff support residents to take responsible risks so that residents can develop an independent lifestyle. EVIDENCE: The records of the 3 residents were inspected. Case files contained recently drawn up care plans although on one file there was nothing in the care plan in terms of social or leisure activities. It was noted that a daily support plan was available for one resident, which covered daily living, physical activities, education, communication and health. On another file there was a positive behaviour assessment and guidelines for staff. This included strategies for staff to adopt when supporting the resident. There was evidence that the 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 11 home had reviewed the needs of the resident on a six monthly basis. A resident said that he had spoken to the reviewing officer about moving into supported living accommodation and that his next review is to be held in September or October. He confirmed that the placing authority holds regular review meetings, which he attends. A copy of the minutes of this meeting in April 2006 were available for inspection and the minutes noted that the previous review meeting convened by them had taken place 12 months previously. The placing authority for another resident had last convened an annual review in 2004 and there were 2 letters in 2006 deferring the date of the next review. There were no minutes on file for the third resident for a review meeting convened by the placing authority and the manager confirmed that contact from this authority was poor. It was noted that case files were large and contained information dating back 6 years. A discussion took place with the member of staff regarding the residents right to choose and to make decisions about their day-to- day life. Although one resident is able to make choices it is more difficult for the other 2 residents to always make their wishes known. She said that residents decide whether to take part in activities and will say “no” if they chose not to. At the weekend residents may want to do different things i.e. one resident may wish to go out while one resident prefers to stay at home. Where possible the resident wishing to go out may be able to join in an outing organised at another of the SFI’s care homes, provided there are sufficient staff on duty in the other care home, or the manager may take the resident out on an individual basis. The resident who has part time employment confirmed that he leads an independent life and comes and goes as he pleases. He is supported with managing his finances although he goes to the bank and withdraws an amount of his choice. Previously the manager has made a referral to Brent Advocacy Services on behalf of the residents. Copies of risk assessments were available for inspection and these included topics such as absconding, cooking, mobility, road safety and the danger of coming into contact with sharp objects. Risk management forms were dated 2006 and identified the hazard, the likelihood, the severity of the hazard, the risk score, the risk provoking factors and the action to be taken to reduce the risk. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to day centres and to employment and this provides them with opportunities to develop their social and independent living skills. Residents are able to use facilities in the community and to fulfil their civic duties. The residents’ quality of life is promoted by the provision of an annual holiday and by attending clubs and taking part in outings they have the opportunity to develop and maintain a stimulating and enjoyable lifestyle. The support of staff enables residents to maintain contact with their families so that residents can enjoy fulfilling relationships. Residents’ rights are respected and involvement in daily routines encourages residents to develop a sense of “home”. Residents have a varied and balanced diet, with dishes to satisfy cultural needs, which contributes towards their wellbeing. EVIDENCE: On the first inspection day one of the residents was getting ready to go to college, one resident was going to a day centre in Harrow and the third resident was going to the SFI day centre in Wembley. One of the residents 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 13 said that they continue to attend college on 2 days per week and that they are taking courses in English, Maths and computer studies. They work part time on 3 days per week and have the assistance of a support worker at the Job Search Centre. The other 2 residents attend day centres Mondays to Fridays. Residents use community facilities including going to the park, the pub and the church. The daily logbooks included references to going to the park, going out for a drink and a meal and going on outings. The manager said that she encourages staff to take the residents out for a walk in the good weather. If residents need transport when they go out they use a taxi, dial-a-ride or the company’s mini bus, which has 17 seats. Residents have voted at elections, if they wished. The member of staff said that 2 of the residents attend the SFI day centre on Wednesday as outings take place on this day. She said that a summer programme is drawn up although the manager said that some changes have been made to the programme due to the very hot weather. She also said that residents attend discos and events organised by a local church. The third resident said that they joined in the outings when they wished. He said that he had been to Florida, early in the year, with 3 residents from another SFI care home and that he had really enjoyed himself. The manager said that the other residents would be going on holiday in the UK in September. Sometimes social events e.g. a barbecue is held in one of the other SFI care homes and a resident said that they were all invited to attend. One of the residents has a family that they keep in contact with and they confirmed that they visit their family on a regular basis or that family members come to visit them at College Road. The resident said that their family members are made welcome by the member of staff on duty and that the visit can take place in the privacy of their room, if they wish. It was observed during the inspection that daily routines were flexible in that residents were having breakfast at a time suitable for being ready to go to work or to the day centre. Residents had the use of the communal areas inside the home and the grounds and it was noted that residents went into the garden when they wished to smoke. Residents are able to choose to spend time in their rooms if they wish to be alone and this is respected. The member of staff on duty knocked on the bedroom door and called out when they were taking a resident a cup of tea in bed. It was observed that there was a good rapport between residents and the member of staff on duty and between residents and the manager. Residents are encouraged to take their dirty plates into the kitchen area when they have finished their meal, help to lay the table, make a cup of tea for themselves and for the other residents etc. During the inspection breakfast was prepared and served and it was noted that it included cereals, toast and preserves and fresh fruit. The member of staff on duty during the first inspection visit confirmed that they had received food 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 14 hygiene training. She was aware of the likes and dislikes of individual residents and of the needs of a resident that is diabetic. Examples were given of how food was provided that met the resident’s dietary needs. A resident was encouraged to choose the ingredients of his packed lunch and it included a sandwich, fresh fruit and low fat yoghurt. Food records were available for inspection, for each individual resident. One record included evidence that a resident had occasionally made his own meal but did not identify the content of the meal. The member of staff said that a resident travelled independently and that she would contact him before preparing the evening meal to see whether he wanted to have a meal prepared by a member of staff or whether he wanted to prepare his own. The menu includes African-Caribbean foods to meet the cultural needs of one of the residents and this resident confirmed that African-Caribbean foods are served and that the meals are good. He said that residents were given the foods that they liked and that this included chicken, sausages and spare ribs. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents receive assistance with or prompting with personal care in a manner, which respects their dignity and records kept in the home must also respect their dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP. However the records kept of the administration of medication must be accurate. EVIDENCE: The assistance given to residents with personal care varies from prompting to direct support. When direct care is given, this in private. During the first inspection visit a resident was being reminded of the time so that the resident could get ready for going to college. It was noted that residents were smartly dressed and one resident enjoys wearing a jacket each day. The jackets are dry cleaned on a regular basis to maintain cleanliness and a selection of suits were also hanging in the wardrobe. The daily logs for individual residents were available for inspection and it was noted that on 3 occasions in the month of July one of the residents was “sent to bed” at 10.30pm. The entries were made by the same member of staff. There was also a record that this 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 16 resident, who is unable to speak, was “making his funny noise”. In the past residents have received help, as necessary, from speech therapists, occupational therapists etc. The minutes of a review meeting convened by the placing authority confirmed that the resident had access to dental and chiropody services and had regular appointments with the psychiatrist. There was evidence on case files that residents had access to routine health screening e.g. blood tests and access to out patient appointments e.g. in respect of diabetes. A letter on file contained a request for an OT assessment for a resident. Residents had a flu jab last autumn, if they wished. The member of staff during the first inspection visit confirmed that they had received medication training. None of the residents self medicate. The storage of medication was inspected and was safe. Medication is delivered to the home in dosette boxes, which have been filled by the chemist. The empty compartments in the boxes were appropriate for the time of day and for the day of the week on which the inspection visit took place. The records of the administration of medication to residents were up to date and complete. It was noted that the medication sheets are pre-printed by the company and although one dose of medication was recorded as 50mg this had been amended by writing 100mg over the top. However looking at medication sheets from November 2005 onwards the dose had been amended on some sheets and not on others. In respect of another resident 2 tablets are supplied i.e. 50mg and 100mg but it is recorded on the sheet as one tablet of 150mg. Although one resident takes 25mg of medication in the evening it is recorded on the sheet for the morning. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The rights of residents are protected by a clear and simple complaints procedure. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: A clear complaints procedure is in place, which includes timescales for each stage of the process and refers complainants to other agencies e.g. the CSCI. Records are kept of complaints made. The manager said that no complaints have been recorded since the last inspection. She also said that matters are resolved at an early stage, before developing into a complaint. One of the residents is unable to speak and the manager was asked how the resident signified their concern or distress. The manager said that if the resident was not happy about something the resident would not have eye contact. A protection of vulnerable adults policy is in place, which includes a whistle blowing procedure. The home has a copy of the local authority interagency guidelines, for each placing authority, in the event of abuse. The member of staff on duty said that they had received training in respect of protection of vulnerable adults procedures as part of their NVQ training. Some staff have also attended pova training organised by the local authority in May 2006. The manager said that no allegations or incidents of abuse have been recorded since the last inspection. Staff have also undertaken understanding aggression and challenging behaviour training courses arranged by a local authority. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 18 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 30 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a comfortable and homely environment with pleasant communal facilities. Single bedrooms provide residents with privacy and a room sufficient in size in which to relax, although some minor repairs are needed in one of the bedrooms. Residents live in a home where standards of cleanliness are good and where bathing and toilet facilities are appropriately placed. EVIDENCE: There is level access to the home and there is a handrail leading from the gate to the front door. The property is well maintained, both inside and out. It is furnished and decorated in a “homely” manner. The premises are bright and airy. The property is in keeping with its neighbours and provides residents with easy access to transport links and local facilities, which are within walking distance. A resident confirmed that they were satisfied with the accommodation. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 20 Each service user has their own single bedroom, with a wash hand basin. Rooms are all a minimum of 10 square metres. They are comfortable and provide the resident with private space, in which to relax. Two of the 3 bedrooms were seen. In one of the resident’s bedrooms it was noted that there was no lampshade around the ceiling light fitting, the curtains were becoming detached from the curtain rail at one edge and the edge of a shelf in the dressing table fitment had come away to show the chipboard underneath. The member of staff said that although there is a cord to pull to open and close the curtains the resident pulls these by hand and this has caused the curtains to begin to become detached from the rail. The bedrooms are situated on the first floor and on this floor there is a bathroom, which includes a toilet, and there is another separate toilet adjacent to the bathroom. There is also a shower room, including a toilet, on the ground floor. The shower room is close to the open plan lounge and dining area. The garden at the front of the house has been redesigned and consists of a paved area, with 2 circles, and borders. These have been planted with trees in the circles and flowers in the borders. It looks attractive and colourful. There is a garden at the rear of the property and access to this from the home is through the patio doors. It is a large area and consists of patio and lawn areas. There are few flowering plants or shrubs. Inside the house there is an open plan lounge and dining area, which is sufficient in size for the 3 residents and which is comfortably furnished and decorated. There is some scuffing of the paintwork where the backs of the chairs, which are against the wall, have rubbed. These chairs are not in use. The parts of the home that were inspected were clean and tidy and free from any offensive odours. The home has an infection control policy and the member of staff on duty said that she had undertaken infection control training as part of her NVQ studies. She said that she was also attending infection control training in August, which had been arranged by the home. Laundry facilities are situated in the kitchen. The home does not service incontinent laundry. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. NVQ training enhances the quality of care provided to residents and the home has now met the target of 50 of its carers having achieved an NVQ level 2 qualification. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents and the home needs to “chase up” the outstanding CRB disclosure and to ensure that references are not open ones i.e. “to whom it may concern”. The quality of care is enhanced by trained staff and records of training undertaken need to be supported by the attendance certificates. Individual supervision sessions enhance the overall support available to staff and are an opportunity to discuss working practices and to encourage personal development. In order to maintain their effectiveness the home must ensure that they take place on a regular basis. Staff appraisals identify the skills and abilities of the member of staff and where training is needed. In order to maintain their effectiveness the home must ensure that they take place on a regular basis. EVIDENCE: The same member of staff was on duty during both of the inspection visits and said that they had completed their NVQ level 2 training and that they would be enrolling for the NVQ level 3 training in September 2006. A review of the staff 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 22 team took place with the manager. Of the 6 staff members on the rota, 1 member of staff has completed their NVQ level 2 studies and 2 members of staff have completed their NVQ level 2 and level 3 studies. A statutory requirement was identified during a previous inspection that 50 of carers achieve an NVQ level 2 qualification. This has now been met. The rota was on display. There was a minimum of 1 member of staff on duty in the home when residents were present. At night the member of staff sleeps in but is on call. The member of staff on duty confirmed that there is clear information about contacting a manager for support, when the manager is not on site. During the day, when residents are at day centre, college or at work the manager spends part of her time in the home and part of her time at head office. Only the time spent in the home is recorded on the rota. A discussion took place with the member of staff in respect of the resident who is unable to communicate verbally. The member of staff gave examples of how she interpreted the wishes of the resident by observing body language and facial expressions. She was able to demonstrate how she communicated effectively with the resident. One of the residents said that all the members of staff are helpful. Five staff files were examined. There have been no new members of staff working in the home since the last inspection. Four of the files contained an enhanced CRB disclosure. The fifth file contained a copy of an application form for an enhanced CRB disclosure, which was dated 28/03/06. The manager said that it had not been returned. Each file contained 2 references although on 2 of the files the references were “to whom it may concern”. Each file contained proof of identity (passport details) and one file related to a member of staff who had student status. The hours recorded on the rota for College Road were in accordance with the number of hours that a student is permitted to work. A copy of the company’s training plan was available for inspection and covered the period 2006-2007. The home has an induction training programme for new staff, which is based on the TOPSS and Croner’s models. It is a 6-week programme and one of the staff files inspected contained a copy of this programme. Some staff have attended a disability awareness course arranged by the local authority and the company has provided in-house equal opportunities training. The staff appraisal format includes an identification of training needs but these are overdue as there was no evidence on the staff files of appraisals being carried out in 2005. Staff files contained training profiles, where courses attended were recorded but the file did not contain all of the relevant training certificates. When staff files were examined the date on the minutes of supervision sessions was noted. There was no evidence that supervision sessions had been held on a regular basis. Staff appraisals were overdue and the manager said that they were in the process of carrying these out. The member of staff 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 23 on duty said that she received individual supervision sessions from the deputy manager and that the last session was almost 3 months ago. She confirmed that staff meetings are held every fortnight and that if staff are unable to attend the meeting a copy of the minutes is available in the home. Copies of the minutes of staff meetings were available for inspection and these had been held on a regular basis. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 24 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): 37, 39, 42 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Quality assurance systems, including both verbal and written feedback, need to be in operation to gather feedback on the quality of the service provided and to assist in the development of the service. The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents and this must include first aid training. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use and the manager needs to ensure that appointments for these checks are made. EVIDENCE: The manager has completed her NVQ level 4 management training. She has managed the home for over 10 years. She has continued to undertake 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 25 periodic training to update her skills and knowledge and said that since the last inspection she has attended seminars in respect of the provision of care. At present verbal feedback about the quality of care in the home is obtained from residents, either during meetings, or at their reviews or on a one to one basis. Verbal feedback is obtained from relatives when they visit the home or attend a social event arranged by SFI. Verbal feedback is obtained from staff during meetings or during discussions with managers. The home also receives verbal feedback from doctors, nurses, the hospital, the dentist, optician and staff in the day centre. The home has now developed a satisfaction questionnaire for relatives and placing authorities and one for residents, which is user friendly. The manager said that she intends to distribute these soon and to use the information obtained in a development plan. At present the development plan for the home is being reviewed and a copy was not available for inspection. The member of staff during the first inspection visit confirmed that they had undertaken training in food hygiene, manual handling and fire safety. They said that they had not undertaken training in first aid. A copy of the risk management form for College Road was available for inspection. It was a health and safety risk assessment and included the areas of manual handling, infection control, lone working and fire. There were servicing certificates available for the fire extinguishers (dated 13th October 2005) and the portable appliances (dated 5th May 2006). The Landlord’s Gas Safety Record was dated 18th July 2006. Certificates, valid at the time of the inspection, were not available for the electrical installation and for the fire alarms/emergency lighting etc. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 26 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 1 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 2 X 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 27 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 2 3 4 Standard YA6 YA18 YA18 YA20 Regulation 15.1 12.2&4 12.4 13.2 Requirement That care plans include an identification of the resident’s social and leisure needs. That times for going to bed are those of the resident’s choosing. That records kept respect the dignity of the resident. That pre-printed medication records include the correct dosage, a separate entry for each different dosage of tablet and the correct time of day when the medication is to be administered. That a lampshade is fitted where a ceiling light fitting is without a shade, that the curtains are attached to the curtain rail and that the edge of the shelf is made good. That the home forwards to the CSCI the CRB disclosure reference number and the date of the disclosure certificate, when the outstanding application has been returned. That reference requests are sent to a named person, or the manager/proprietor of a business and are not provided by the DS0000017436.V289603.R01.S.doc Timescale for action 01/11/06 18/09/06 18/09/06 01/10/06 5 YA26 16.2 01/10/06 6 YA34 19.4 01/10/06 7 YA34 19.4 18/09/06 4 College Road Version 5.1 Page 28 8 YA35 18.1 9 YA36 18.2 prospective employee addressed “to whom it may concern”. That training profiles are matched by the corresponding certificates for the training attended. That individual staff supervision sessions are carried out at least every 2 months, recorded, and a copy of the minutes of the session kept on the staff file. (Previous timescale of 1st June 2006 not met). That staff appraisals are carried out on an annual basis. (Previous timescale of 1st June 2006 not met). 01/11/06 31/10/06 10 YA36 12.5 31/10/06 11 YA39 12 13 14 YA39 YA42 YA42 24.1&24.3 That written feedback regarding the quality of care provided in the home is obtained from relatives of the residents and from the placing authority etc. That this information is collated and used to help plan the development of the service. 24.1&2 That the home forwards a copy of the updated development plan to the CSCI. 13.4 That all staff working in the home have undertaken first aid training. 13.4 That the home ensures that the electrical installation and the fire alarms/emergency lighting are serviced and that a certificate is available for inspection. 31/12/06 01/11/06 01/11/06 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000017436.V289603.R01.S.doc Version 5.1 Page 29 4 College Road 1 Standard YA6 2 3 4 5 6 7 8 9 YA6 YA17 YA20 YA24 YA28 YA28 YA33 YA34 That the home contacts the local authority, in writing, when their annual review meeting is due and asks for a date to be set. A copy of the letter is kept on the resident’s file. That the home archives documents on case files which originate prior to 2 years from today’s date. That if a resident prepares their own meal the record states what the meal consisted of. That the home asks the pharmacist to supply medication record sheets with the dosette boxes. That the home uses Velcro to attach curtains to the curtain rail. That the garden at the rear of the property has flowering plants and shrubs to provide seasonal colour. That the scuffed paintwork behind the backs of the dining chairs is made good. That the manager’s hours spent at head office are recorded on the rota. That the home contacts the CRB for news of the disclosure application that is still outstanding. 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 Page 30 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 4 College Road DS0000017436.V289603.R01.S.doc Version 5.1 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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