Inspection on 10/10/07 for 63 Kingsley Road

This inspection was carried out on 10th October 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

63 Kingsley Road 04/10/06

63 Kingsley Road 16/11/05

63 Kingsley Road 07/06/05

63 Kingsley Road 11/01/05

63 Kingsley Road 13/09/04

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 63 Kingsley Road 63 Kingsley Road South Harrow Middlesex HA2 8LE Lead Inspector Judith Brindle Key Unannounced Inspection 10th October 2007 08:25 63 Kingsley Road DS0000017575.V345973.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 63 Kingsley Road DS0000017575.V345973.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. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Kingsley Road Address 63 Kingsley Road South Harrow Middlesex HA2 8LE 020 8422 4277 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) Clover Residents Miss Jasmin Johnson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: 63 Kingsley Road is a care home registered to provide personal care and accommodation for three adults with a learning disability. The home is owned by Clover Residents (Organisation). The house is a semidetached property, located in South Harrow, close to a variety of amenities, which include shops, restaurants and banks. Local public transport facilities include train and bus services. There is a large accessible park located very near to the care home. The premises are in keeping with other houses in the residential area. All the resident’s bedrooms are single and located on the first floor. The communal areas of the care home are situated on the ground floor. There is an accessible enclosed garden located at the rear of the property. There is parking on the street at the front of the house but it is restricted to residents. The home has accessible information about the care home and the service provided. Information in regard to fees is available from the registered person. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in October 2007. There were two vacancies at the time of the inspection. I was pleased to meet and spend sometime with the person living in the home, and with the care staff member on duty. The registered manager was present during most of the inspection. Due to the vocal communication needs of the person living in the home, the resident was unable to respond to questions other than to a very limited degree, so observation was a significant tool used in this inspection. Documentation inspected included, resident’s care plans, risk assessments, staff training records, and some policies and procedures. The inspection included a tour of the premises. Assessment as to whether the requirements and recommendations from the previous key inspection (4th October 2006) had been met also took place during the inspection. 26 National Minimum Standards for Adults, including Key Standards, were inspected during this inspection. Prior to this unannounced key inspection the registered manager supplied the Commission for Social Care Inspection a completed Annual Quality Assurance Assessment (AQAA) document. This includes required information from the owner and/or registered manager about the quality of the care home and their planned improvements to the service. Most sections of this document were completed, but there were areas (such as how the home has improved over the last year and plans for future improvements), which could have been completed and/or more comprehensively documented. Reference to some aspects of this AQAA record will be documented in this report. The inspector thanks the person living in the care home, staff and the manager for their assistance in the inspection process. What the service does well: The care home has a very warm welcoming atmosphere, and homely, very clean, bright environment. The home has an enclosed well maintained garden. Residents’ contact with relatives and others (as agreed by the residents) is fully supported and enabled by the care home. Staff are knowledgeable and understanding of the resident’s varied needs, and receive regular and appropriate training to ensure that they have the ability to carry out their role and responsibilities. There is a low staff turnover rate. A 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 6 significant number of staff have achieved an appropriate National Vocational Qualification (NVQ) in care. Staff support residents to take part in a variety of preferred activities. The registered manager is experienced, competent and keen to put into place, systems and practice to continue to improve and develop the service. 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. 63 Kingsley Road DS0000017575.V345973.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 63 Kingsley Road DS0000017575.V345973.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): Standards 1, 2, and 4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective residents to have the information that they need to make an informed choice about where to live, and to ensure that their needs are assessed prior to their admission to the care home, but the initial assessment could be further developed, and the format of some documentation about the service could be more accessible to people using the service. EVIDENCE: The statement of purpose, and the service user guide documents include information about the service provided by the care home. The statement of purpose has been reviewed this year, and includes some attractive photographs of the home, but there are some areas of the document, which could be, updated for example the registration category information and updating information about the registered manager’s qualifications. The manager reported that all people who are admitted to the care home receive a copy of the service user guide. This guide has information, which is linked with other care homes that are registered with the owner, and includes some pictures. It includes the format of the ‘service user and proprietor contract’. In regard to the communication needs of the resident (and possibly prospective residents with similar needs) the manager could continue to review the format (i.e., audio format) of the service user guide (with the person living in the home if able, and with future residents), to improve its accessibility to 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 9 those who have significant, and/or varied communication needs. This was discussed with the registered manager. The care home has an admission procedure. There have been no recent admissions to the care home. The resident has lived in the care home for a significant number of years. There were two vacancies at the time of the inspection. The manager spoke of being in the process of assessing a prospective resident, and that this person had commenced visits to the care home, as part of their transition process. The home provided respite care to a person on several occasions. The manager informed me that a comprehensive initial assessment is carried out prior to anyone being admitted to the care home, (with participation from the prospective resident, relatives and significant others) so as to ensure that the home can meet the needs of the prospective resident. I was shown evidence of an initial assessment. This assessment documentation included assessment of potential risks, and assessment of health, social, cultural, religious and welfare needs. There were gaps in recording of some of the assessment information. This should always be fully completed. Records and the manager confirmed that the funding Local Authority also carry out a comprehensive assessment. The manager spoke of the on going assessment process during the prospective resident’s visits to the home, and of visits by staff to his/her present home. It was evident that the manager and staff were fully aware of the importance of well planned prospective residents introductory visits to the care home, and of close liaison with staff from the previous home, and with the Care Managers of the funding Local authority. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People who use this service experience good outcomes in this area. 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. There could be some development in the care plans to ensure that resident’s assessed needs, changing needs and personal goals are more reflected in their individual care plan. Residents are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. EVIDENCE: The person living in the care home has a plan of care. This includes a record of examining, and recording some areas of the person’s life, and identifying some needs. There is some documented staff guidance to ensure that the resident receives appropriate care and support from staff to meet their needs and preferences. The care plan recorded evidence of having been reviewed regularly, with family and care manager involvement. The content of the care plan includes health needs, day care/leisure needs, communication needs and 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 11 personal care needs, and a record of some personal ‘likes’ and ‘dislikes’. This care plan could be improved and further developed to ensure that there is recorded evidence that all needs are recognised, and action put in place to meet those needs, such as religious needs, cultural needs, dietary needs, financial social contact needs, and sexuality needs. The care plan should be a ‘working document’, and be more ‘person centred’, and include detail of how each resident’ aspirations/goals, are to be met. Goals/aims (short term and long term) of the resident need to be clearly recorded and show evidence of frequent review and evaluation. This was discussed with the manager. The format of the care plans should include evidence of a variety of different and creative methods to help people who use the service to contribute to the development of their care plan, and the ongoing process of review. Records confirmed that the care plan inspected was regularly reviewed. Daily’ and night resident’s progress records are documented. The content of these records is varied, some records were comprehensive, positive, and informative, others could be further developed and improved in regard to some of the recorded wording, which could be more encouraging, and age appropriate. This was discussed with the registered manager who spoke of staff having received training in completing records. She spoke of how she would closely monitor the ‘daily’ progress records. Staff were observed to interact with the resident in a sensitive and respectful manner during the inspection. It was evident that the care staff member had a good understanding of the significant needs (particularly the communication needs) of the resident. Choice was offered to the resident frequently, and the person was supported in making decisions. Staff spoke of having an understanding of Makaton signing, which includes some of the signs used by the resident. Risk assessments include areas of potential risk, such as participation in household duties, and in regard to healthcare needs, and are managed positively to help the people using the service to lead the life that they want. These recorded evidence of having been recently reviewed. 63 Kingsley Road DS0000017575.V345973.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): Standards 12, 13 14, 15, 16, 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The resident living in the care home has the opportunity to take part in a variety of activities including those promoting personal development, and this person is supported to maintain contact with family/significant others. The person living in the care home has their rights respected, and their responsibilities are recognised in their daily lives. Meals are varied and wholesome. EVIDENCE: Staff and records confirmed that the person living in the home had the opportunity to participate in a variety of preferred activities. The resident attends a day resource centre during the week days. Records confirmed that this person undertook several activities at the centre, including music sessions. The resident also participates in many activities at home and during the evening. These include regular walks to the local park, local shopping, going to the cinema, and participating on day trips. Staff spoke of the resident 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 13 having recently enjoyed their birthday party, (when the person using the service was joined by friends) and of having benefited from a long weekend away. The resident has the opportunity to attend church regularly. Records confirmed that the person using the service had attended the local college and completed some educational courses, including ‘sensory art’. It is evident from a previous inspection, (when another resident was living in the home), that this person was supported fully by staff in developing employment skills and in taking up paid work (this resident has now moved on to a more independent living environment). The care home has a consistent record in supporting residents to develop their skills and confidence to improve their quality of life. The person using the service has the opportunity to develop and maintain personal and family relationships. Staff spoke of the close contact that the resident has with their family. The registered person does not impose restrictions on visits (unless requested by the resident concerned). Daily routines that promote independence and choice are assessed and documented in the care plan. The person living in the home was observed to have unrestricted access to communal areas of the home, and their bedroom. The resident moved freely within the home, and was observed to participate in some everyday living skills activities, including clearing their plates off the table. Staff spoke of shopping for food once a week and of purchasing (with the resident) locally, fresh produce. Fresh fruit was accessible in the care home, and the resident ate fruit as part of their breakfast. I was informed that meals are generally chosen on a daily basis. Meals recorded were judged to be varied, and wholesome, and meet the cultural needs of the resident. The staff member on duty was knowledgeable of the particular dietary needs of the resident, (this person due to their weight needs, has a ‘healthy eating’ plan). The care staff member spoke of how staff gained knowledge of the food ‘likes’ and dislikes’ of this person using the service, particularly in regard to their significant verbal communication needs. The resident was observed to have their breakfast during the inspection. This meal was unhurried and the resident was judged to enjoy it. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19, 20 People who use this service experience good outcomes in this area. 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. Systems are in place to ensure that medication is stored and administered safely. EVIDENCE: The care plan recorded assessment of the resident’s personal care and health needs. It was evident that the person living in the care home is having the support and care they require to meet their personal care needs. Preferred morning and evening routines were documented. Privacy was respected when personal support was provided to the resident during the inspection. The resident has a key worker, and the manager spoke of the importance of consistency, choice, and continuity in the support and care provided to the resident. Records confirmed that personal care needs of the resident were discussed during the review of their care plan. At the time of the inspection the person using the service was well dressed, and it was evident that she had had a recent manicure. Staff and records confirmed that residents have their health needs monitored, and have access to appropriate intervention, care, and treatment from a 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 15 variety of healthcare professionals. These include GP appointments, optician, dentist, and foot care (records confirmed that staff have received appropriate training from a qualified chiropodist, and a risk assessment has been carried out to enable staff to cut the resident’s toe nails, due to the resident’s anxiety at attending chiropody appointments) and treatment. The care home has a medication policy/procedure. This has recently been reviewed. The home has appropriate medication storage systems, and the manager spoke of the medication training that staff complete, and of the ongoing monitoring that she carries out to ensure that they are administering medication safely. It is recommended that a record of this monitoring be maintained. At the time of the inspection no mediation was being administered as I was informed by staff that the resident is at present not prescribed any. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 16 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): Standards 22, and 23 People who use this service experience good outcomes in this area. 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 appropriately, that residents are protected from abuse, neglect and self-harm. The safeguarding adults procedure could be improved. EVIDENCE: The care home has a complaints policy. This is in written format, and picture format, and recorded in the service user guide documentation. There are no recorded complaints. The resident due to their verbal needs could not communicate to me that they knew how to complain. A staff member who kindly spoke with me was fully aware of the reporting and recording procedures in response to a complaint/concern made from a resident and/or visitor. The home has a protection of vulnerable adults policy. This procedure was inspected, and included most required information. There needs to be evidence that it has been reviewed to ensure that it is evident that the care home contact the Local Authority (and Commission for Social Care Inspection (CSCI), and the police if a criminal offence) without delay, prior to an investigation being carried out by the care home. Investigation of an allegation or suspicion of abuse should be agreed in a multi disciplinary strategy meeting. This was discussed with the manager who was confident that she had updated the procedure, but that it could have possibly been removed from the file. She reported that she would supply a copy to the Commission. It was evident that there had been a satisfactory safeguarding 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 17 adults policy available for inspection during the previous key inspection in October 2006, but this version was not accessible on the day of this inspection. There should be a procedure in place to ensure that there is at all times accessible copies of the care home’s policies and procedures, such as the up to date safeguarding adult’s procedure. Staff who spoke with the inspector were knowledgeable of the reporting, and recording procedures in response to an allegation or suspicion of abuse. Records and staff confirmed that staff had received protection of vulnerable adults training. The manager spoke of having obtained the up to date lead Local Authority Safeguarding Adults policy/procedure, and records confirmed that she had also obtained the safeguarding adults procedure of the funding Local Authority of a prospective resident. The care home also has policies and procedures in regard to counter bullying, whistle blowing, anti harassment, gift policy, and for ‘managing violent situations’. The resident’s money and records of expenditure, and incoming payments were inspected. Appropriate recording and monitoring of monies held by the resident takes place. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely, clean and comfortable. The premises are suitable for the care home’s stated purpose. EVIDENCE: The home is located in South Harrow, within walking distance of a variety of amenities, and bus and train public transport facilities. The environment of the care home provides for the individual requirements of the person using the service. The environment is very clean, bright, homely and well maintained. There has been redecoration of several areas of the care home since the previous key inspection. A bedroom was being redecorated during the inspection. The upstairs bathroom has some areas of paintwork, which should be repainted. The toilet seat of the toilet on the ground floor is very ‘wobbly’ and needs repair. At present the office is located in the dining area of the home. This is not good practice, and was discussed with the registered manager who spoke of the plans to move the office files and equipment. The registered person should 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 19 seriously consider plans for an office area that is located away from the dining area. This is of particular importance in regard to the likelihood of the care home having no vacancies in the near future, and was a previous recommendation. The home is clean and odour free. Soap and hand towels were located in the bathrooms/toilets inspected. The laundry facility is located next to the kitchen, but a door separates the two rooms, and the home has a risk assessment in response to the issue of laundry needing to be carried through the kitchen to the laundering facilities. A staff member was observed to wear protective clothing as and when needed. Records confirmed that staff had received infection control training. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,34, 35 and 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent, supervised and skilled to enable them to carry 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: A staff rota was available for inspection. This confirmed that there is one staff member on duty at all times when the resident is at home, including a staff member completing a ‘sleep in’ duty at night. The registered manager spoke of having recently adjusted her shifts to ensure that she was present in the care home during the late afternoon when the resident had home from day activities. The staff are experienced and have worked in the care home for sometime, and I was informed that there was a very low staff ‘turnover’ rate. Regular planned staff meetings take place. The staff member on duty spoke of knowing the resident well, and was observed to interact with the resident in a positive and sensitive manner. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 21 The manager confirmed that four of six staff had completed an NVQ (National Vocational Qualification) level 2 or above, and that one staff member was in the process of working towards this qualification. Another staff member had completed a foundation in care training course and was being supported in achieving further qualifications. This is positive. The registered manager spoke of the induction programme that staff that staff receive when commencing employment. This includes a period of ‘shadowing’ more experienced staff. Records confirmed that staff induction takes place. Staff and records confirmed that staff had recently received statutory training, that includes food and hygiene training, manual handling, and health and safety training, moving and handling, fire training, 1st Aid training, and medication training. I was informed that staff training, generally includes ‘in house’ training courses using video/DVDs, during which, staff complete a questionnaire, in regard to their knowledge having been gained from the training. I was informed during a previous inspection that this training is repeated if required. Staff training also includes specialised training appropriate to the roles and responsibilities of staff so as to ensure that all staff can meet the varied needs of the person living in the care home, and of prospective residents. This includes ‘break away’ training, and training in meeting dementia care needs of people who in the future might use the service. Each staff member has an individual training record. The manager spoke of having (with other staff) recently having completed ‘risk management’ training carried out by an outside training provider. The manager and another staff member spoke positively about this training course. The home has a recruitment and selection policy/procedure. Five staff personnel files were inspected. This documentation included evidence that required and appropriate recruitment procedures had been carried out. Staff job descriptions, and a copy of the staff General Social Care Code of practice were accessible in this documentation. A staff member confirmed that she receives regular supervision. A record of planned staff supervisions was displayed, and recorded staff 1-1 supervision records were available for inspection. The manager informed me that staff were in the process of receiving appraisals. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. 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. So far as reasonably practicable the health, safety, and welfare of residents and staff is promoted and protected. EVIDENCE: The registered manager has spent several years working with adults who have a learning disability, and managing the care home. The registered manager informed the inspector that she had completed the NVQ level 4 management and care qualification, and that she ensures that she attends training to up date her skills. It was evident that the manager works hard to meet inspection 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 23 requirements and recommendations and is keen to continually improve the service provided to residents by the care home. Records confirmed that the quality of the service is monitored to ensure that it meets resident’s needs and that plans for improvements are instigated. This includes reviewing care plans and other documentation including some policies and procedures. The home completes an annual development plan of the service. An up to date plan was available for inspection. The manager spoke of supplying satisfaction surveys to residents (dependent on assessed ability) and their relatives on a regular basis. Other stakeholders (such as care managers, GP, community nurses etc) should also be supplied with questionnaires about their view of the service. There was evidence that required equipment checks are carried out. These included electrical and gas safety checks. Fire drills take place as required, and the care home has an up to date fire risk assessment. The home has a recorded health and safety risk assessment. There were no obvious health and safety issues apparent during the inspection. Household cleaning products are kept securely. Accidents and action taken to prevent further occurrence of accidents/incidents are recorded. An up to date employers liability insurance certificate was displayed. 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 24 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 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 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 3 3 3 X 3 X X X X 3 X 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 12(1) 14(1) 15(1) Requirement The content of the care plan needs be improved and further developed to ensure that there is recorded evidence that all needs are recognized, (such as religious needs, cultural needs, financial social contact needs, mobility needs, and sexuality needs). To ensure that it is evident that the service can meet all current and changing needs of people using the service. The Safeguarding Adults procedure needs to be reviewed to ensure that it is evident that the care home contacts the Local Authority (and CSCI, and police) without delay, prior to an investigation being carried out by the care home. The toilet seat of the toilet on the ground floor is very ‘wobbly’ and needs repair. Timescale for action 01/01/08 2 YA23 13(6) 01/12/07 3 YA24 23(2) 01/12/07 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 26 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 manager could review the format (i.e. audio format) of the service user guide (with the person living in the home if able, and with future residents), to improve its accessibility to those who have varied, and significant communication needs. • The statement of purpose information should be reviewed to ensure that records about the manager’s qualifications and the registration category are up to date. Assessment information in regard to resident’s needs should always be fully completed. To ensure that there is evidence that the care home can meet that person’s needs. The care plan should be a ‘working document’, and be more person centred, and include detail of how each resident’s aspirations, are to be met. The format of the care plan should include evidence of a variety of different and creative methods to help people who use the service to contribute to the development of their care plan, and the ongoing process of it’s review. The wording/content of the ‘daily’ progress records could be developed and improved. The manager should complete a record of when she monitors the competency of staff administering medication. There should be a procedure in place to ensure that there is at all times accessible copies of the care home’s policies and procedures, such as the up to date safeguarding adult’s procedure. The upstairs bathroom has some areas of paintwork, which should be repainted. The registered person should seriously consider plans for an office area that is located away from the dining area. This was a previous recommendation. Stakeholders such as care managers, GP, community nurses etc, should also be supplied with questionnaires about their view of the service. • 2 YA2 3 YA6 4 5 6 YA6 YA20 YA23 7 8 9 YA24 YA24 YA33 63 Kingsley Road DS0000017575.V345973.R01.S.doc Version 5.2 Page 27 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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