Inspection on 22/05/07 for 89-91 Bessborough Road

This inspection was carried out on 22nd 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

89-91 Bessborough Road 19/04/06

89-91 Bessborough Road 10/02/06

89-91 Bessborough Road 06/06/05

89-91 Bessborough Road 13/01/05

89-91 Bessborough Road 10/08/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 89-91 Bessborough Road 89--91 Bessborough Road Harrow Middlesex HA1 3BD Lead Inspector Judith Brindle Key Unannounced Inspection 22nd and 30th May 2007 09:15 89-91 Bessborough Road DS0000017519.V337558.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 89-91 Bessborough Road DS0000017519.V337558.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. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 89-91 Bessborough Road Address 89--91 Bessborough Road Harrow Middlesex HA1 3BD 020 8423 1116 020 8864 4191 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) Harrow Consortium for Special Needs Manager post vacant Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: 89 - 91 Bessborough Road is a care home for up to 12 adults who have enduring mental health problems and require medium to long-term support. The home is run by Harrow Consortium for Special Needs (the registered provider), staffed by the Family Welfare Association, and with premises supplied by Paddington Churches Housing Association. At the time of inspection there were no vacancies. The home is situated on a busy link road to Harrow that includes bus access. It is a few minutes walk from Harrow town centre where there are shops, leisure facilities and further transport links. There is space for two cars to park on the forecourt, and there is unrestricted but regularly used parking on the road. The home is made up to two interlinked semi-detached properties that span three floors. Access is by stairs only. Bedrooms are situated on the 1st and 2nd floors. Each person using the service has his or her own single room. The ground floor has communal living and dining rooms, a conservatory, a laundry room, and office space. 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. 89-91 Bessborough Road DS0000017519.V337558.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 with the staff on duty. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The 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. 26 National Minimum Standards for adults (including Key National Minimum Standards) 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 happy living in the home. It was evident from talking to people living in the home, and from observation that they participate fully in their home, and are continually consulted and kept updated about the running of the home. People living in the care home are supported by staff to make life choices and to develop their independence, and to be empowered. Residents are fully involved in the care home, and participate in completing household duties including cooking and housework. Holidays for residents are a regular feature of the care home. There is close liaison with healthcare professionals and other specialists as and when required/needed by the residents. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 6 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. The manager is very experienced, and competent. It was evident that he strives to continually improve the quality of the service for those living in the home. What has improved since the last inspection? What they could do better: The manager needs to be registered with the Commission for Social Care Inspection. Continue to develop the care plans into being more ‘Person Centred’, so that it is evident that the resident is central to and participates fully in their care plan. Reporting significant events to the Commission for Social Care Inspection must always take place. A maintenance issue in regards to a bathroom needs to be resolved. There needs to be evidence that electrical safety checks have been carried out 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 7 There are two previous requirements from a previous inspection that need to be met. 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. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 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 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. Arrangements are in place to ensure that prospective resident’s needs are comprehensively assessed prior to their admission to the care home. EVIDENCE: The statement of purpose and the service user guide documents are accessible, and include comprehensive information about the service provided by the care home. Both documents have been recently reviewed. The inspector was informed that people using the service had been fully involved in the review of the Service User Guide. The manager reported that all the people living in the care home had been provided with this documentation. The care home has an admission procedure. Staff reported that prospective residents receive a comprehensive assessment of their needs, and have the opportunity to visit the home as many times as they wish prior to moving in to the care home. These visits generally include a weekend visit including staying overnight. A resident spoke of visiting the care home prior to ‘moving in’. A four week assessment period follows admission. A care plan inspected 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 10 recorded evidence that this assessment procedure was carried out as documented. There have been no recent admissions to the home. Care plans inspected included assessment information from the funding Local Authority and from healthcare professionals. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that 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. Risks are managed positively to help people using the service to lead the life that they want. EVIDENCE: All the residents have an individual plan of care. Four care plans were inspected. These documents included a photograph of the residents, and comprehensive information in regard to assessment of their needs. These needs include personal care needs, health needs, activity/education needs, and religious and cultural needs, and emotional needs. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 12 The care plans included staff, and residents recorded guidance to meet these assessed needs, and were signed by the resident and key worker. The manager spoke of the ways that the care plans had been recently developed, and improved and that this development of the care plans was ongoing to ensure that each resident is central to their plan of care (Person Centred Plan) and participates fully in this plan. It is recommended that care plans continue to be developed and improved with residents’ participation. The care plans inspected recorded evidence of being linked to the Care Programme Approach (CPA) review meeting decisions, in regard to the mental health needs of residents. This meets a previous inspection requirement. The care plans inspected recorded evidence of having been reviewed regularly. The inspector was informed that these reviews increase in frequency when the needs of the residents change. Monthly summaries of the progress of residents were documented in care plans inspected. These included information from key worker/resident meetings and included review of mental health needs, medication needs, health, activities and financial needs. Staff reported that Key worker meetings varied in regularity according to the assessed needs and preference of the people living in the care home. Care plan reviews, which include participation from residents, their relatives, care manager and significant others also take place. Residents spoke of making choices. These include shopping for clothes, toiletries, food, and choosing preferred activities. During the inspection, staff were observed to consult with residents, negotiate with them, and to support them in making decisions. A resident confirmed that she could go to bed and get up when she wished. Residents have the opportunity to participate in regular resident meetings. It was evident from speaking to residents, observation, and inspection of records that the care home promotes the empowerment of residents, and respect is at the forefront of the service provided by the care home. The care home has a ‘resident’s money and financial affairs’ policy/procedure. The inspector was informed that people living in the care home manage their own monies with varying levels of support from staff. Records confirmed that financial records were maintained, and receipts were available for inspection. A previous requirement in regard to meeting the financial needs of a person using the service was judged to have been met. The home has a risk assessment policy. Staff had signed that they had read the risk assessments. The manager spoke of how risk assessments had been developed since the previous inspection. A previous requirement in regard to developing risk assessments was judged to have been met. Records confirmed that people living in the home are supported and enabled to take responsible risks. Risk assessments are recorded in each resident’s plan of care. These include health and safety risk assessments, road safety, 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 13 handling monies and kitchen safety. Following the inspection the manager reported that a risk assessment would be developed in regard to a resident getting taxis home. The care home has a missing persons procedure. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 14 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. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community. People living in the care home have the opportunity to take part in a variety of activities including those promoting personal development, independence, 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 respected and their responsibilities are recognised in their daily lives. Meals are chosen by people using the service, and are varied and wholesome, and meet the cultural and dietary needs of the residents. EVIDENCE: 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 15 People living in the home kindly spoke to the inspector about the numerous preferred activities that they participated in. Residents confirmed that they make decisions about what they want to do during the day, and at weekends. Activities include attendance at the local college, participating in sessions at day resource centres, and other leisure pursuits of their choice, such as going to the cinema. A resident spoke of attending an Asian resource centre, which she spoke of enjoying. A staff member spoke of plans to accompany a resident to see an Asian play in which Gujarati will be spoken. Records and residents confirmed that the people using the service have their views sought, and that their varied interests are considered when planning (with the resident) the routines of daily living, and when arranging activities both in the home, and in the community. Residents spoke enthusiastically of a recent weekend break that they had had at a well known health farm facility. Another resident spoke of a recent holiday abroad that he had thoroughly enjoyed. It was evident from speaking to people using the service, records, and staff that the care home actively supports and promotes the residents to make informed choices, which includes developing and maintaining family and personal relationships. Residents spoke of the contact that they had with relatives and significant others. A resident kindly showed me the pay phone, which people using the service can freely access. Residents were observed to access and open their own mail. Staff were observed to have understanding and respect for residents privacy. People living in the home spoke of their involvement in household duties including cleaning their own rooms. A resident kindly explained the house duty rota in which all residents participate. Duties include cooking, and cleaning. The care home has a menu, which is displayed. Residents spoke of choosing preferred evening meals, on a weekly basis, and that lunches were individually chosen on a daily basis. Residents spoke of enjoying the meals, and that they met their cultural/ethnic, religious and specific dietary needs including vegetarian needs. Several people living in the care home confirmed that they participated in shopping for food items of their personal choice. Two residents spoke of enjoying cooking, and one was observed to cook their evening meal. Other residents made snacks of their choice for their lunchtime meal. Fresh fruit, vegetables and a variety of dried and frozen foods were accessible during the inspection. Food stored in the fridge was suitably labelled. Residents who kindly spoke to the inspector were knowledgeable of healthy eating. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18,19, and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s individual personal and healthcare needs are met. Medication is generally stored and administered safely. EVIDENCE: Care plans inspected recorded evidence that people who use the service receive effective personal, and healthcare support, according to their individual needs. Records, and from speaking to staff it was evident that staff are aware and knowledgeable in their role of supporting residents to access healthcare, including treatment and care from healthcare specialists. Records confirmed that people living in the care home have access to a GP, dentist, optician, chiropodist, and attend hospital appointments as and when needed. Staff reported that residents are encouraged to be fully involved in the management of their healthcare needs, and their changing healthcare needs. This consists of arranging and attending health appointments, with varying levels of staff support according to their assessed needs. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 17 The care home has a medication policy including procedure and guidance in regard to the administration of medication. Medication storage and administration systems were inspected. Medication is stored securely. There were no gaps in recording on the medication administration records. PRN medication (medication administered as and when needed) guidance is documented. This needed further development to ensure that there was clarity in regard to following safe procedures when administering this medication i.e. not to administer more than eight tablets of an ‘pain killer’ tablet within 24 hours. A staff member developed and improved the PRN guidance following the first day of the inspection. Staff reported that they received medication training. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 18 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 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 for ensuring that complaints are taken seriously and handled objectively. Arrangements are in place to ensure that service users are protected from abuse, but reporting procedures need to be improved. EVIDENCE: The care home has a complaints procedure. It is recorded in the service user guide and statement of purpose. This policy includes timescales for responding to complaints. A resident showed me a copy of the complaints procedure. Residents who kindly spoke with the inspector were clear about whom they would talk to if they had a complaint; one resident spoke of speaking to their key worker or the manager. Records confirmed that residents were confident in reporting concerns/complaints and that action was taken to resolve them. The care home has a protection of vulnerable adults procedure. This policy was reviewed and amended during the inspection to include timescales for response from staff, which meets a previous requirement. Incidents were appropriately recorded, but there were three recorded significant incidents, which had not been reported to the Commission for Social Care Inspection (CSCI). This was discussed with the manager. If the manager is not available to report significant events (i.e. when ill), he must ensure that staff are knowledgeable of the safeguarding adults policy. Following the inspection, the manager supplied the Commission with details of steps taken by him to amend 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 19 this policy and that each staff member has been supplied with a copy of the procedure and that they sign when they have read the document. This is positive, but action taken by staff in response to incidents including any suspicion of abuse, should be monitored closely. Following the inspection the manager supplied the Commission with documentation in regard to an incident, which confirmed that the Local Authority, and police had been informed of it, and that action was being taken to investigate this issue. It was evident that a resident was aware of safety procedures in regard to checking the identity of visitors to the care home. The care home has a whistle blowing policy, and a counter bullying procedure. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 20 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. There is a maintenance issue that needs to be carried out. Residents bedrooms are individually personalised, and meet their individual needs. The care home is clean, and odour free. EVIDENCE: A person using the service kindly showed the inspector around the care home. The physical environment of the home provides for the individual requirements of the people who use the service. The home is clean, light and airy. It was evident from speaking to residents and through observation, that people living in the care home are supported and encouraged to see the home as their own. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 21 The home has an enclosed garden. A resident reported that there were plans to cut the grass. The home has good access to local amenities and facilities. It is located a short walk from local shops, and from central Harrow where a variety of shops, restaurants, banks, and other amenities are located. A resident spoke of ‘going into Harrow most days’, and of enjoying this activity. Residents spoke positively of the location of the care home, and it was evident that community facilities including public transport was used regularly by residents. People living in the home were observed to freely access their bedrooms and all communal areas of the home. Some maintenance needs have been carried out. These include laying new carpets in corridors and hallways of the care home, and repairing a possible trip hazard located near the ‘smoking room’. Residents and staff reported that a bathroom on the 1st floor is not in use due to repairs being needed (a new floor), and that residents had to use another of the care home’s bathrooms. It was reported by staff that this issue had been reported to the housing association that is responsible for major repairs, but that this repair was still outstanding. The bathroom on the 1st floor (in 91) must be repaired promptly. The manager reported that the office/ staff ‘sleep in’ room was to be shortly refurbished. A resident kindly showed the inspector their room. This was individually personalised with a variety of personal possessions. The resident spoke of being happy with their room. The home has an infection control policy/procedure, which has recently been reviewed. The laundry facilities are located away from food preparation and food storage areas. Residents and records confirmed that people living in the home participate in the care of their laundry. The inspector was informed that a new washing machine had been purchased recently. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 22 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, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff receive training 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, but there needs to be evidence that all recruitment requirements have been carried out. EVIDENCE: Staff were observed to interact with people living in the care home in a positive and respectful manner. Staff and residents confirmed that staff have understanding and knowledge of the varied needs (including cultural needs) of the people living in the care home. People living in the care home spoke positively about the staff, and it was evident during the inspection that residents knew staff well and communicated with them freely. A resident spoke of the staff being ‘nice’. Residents who kindly spoke to me knew who their key worker was and spoke of the key workers as being supportive. Records confirmed that the home has a staff code of conduct. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 23 It was evident that consistency in the way residents are supported by staff is a prominent aim/theme of the care home. The manager spoke of having worked closely with staff to ensure that they support residents to be as independent as possible, and to listen and respect the views of the people living in the care home. The staff rota was accessible. There is a small staff team. There are generally two staff on duty (and the manager during weekdays), and one staff who completes a ‘sleep in duty’. Staff reported that there were two care staff vacancies, which were being currently filled by long term agency staff. An agency staff member was on duty during the inspection. It was evident from talking to her and to residents that she had a good understanding and knowledge of the resident’s multiple needs. Other staffing issues include long term staff sickness, and a staff member shortly planning to take up a post elsewhere. The inspector as informed that the post of deputy manager was to be advertised shortly. In regard to current staffing issues, recruitment for staff vacancies including the deputy manager post need to take place promptly to ensure that the service is proactive rather than reactive in its provision of staffing in regard to its planning for the needs and potential changing needs of people who use the service. It was evident that a deputy manager would be of positive benefit to the care home to assist the manager in ensuring that all aspects recorded in the statement of purpose are carried out. Staff job descriptions were available for inspection. Staff confirmed that residents are involved in the recruitment of staff. Prospective staff visit the care home, and meet the residents, and that the views of people using the service about prospective staff are listened too. Three staff personnel files were inspected. Two of these included required information and documentation. One staff file did not include evidence that an enhanced Criminal Record Bureau check had been carried out, nor that an application form had been completed, and references obtained. The manager assured the inspector that appropriate recruitment practices had been carried out. Following the inspection the manager informed that he had contacted the human resources department and that copies of the missing documentation would be supplied to the manager. The Family Welfare Association has a staff training plan. Records and staff confirmed that staff have the opportunity to receive varied training, including a comprehensive staff induction programme to ensure that they are competent in meeting all the resident’s needs. The manager informed the inspector that new staff complete a basic induction programme then complete a foundation induction course prior to proceeding onto NVQ care training. He spoke of plans to ensure that two fairly new staff had the opportunity to carry out an NVQ level 2 in care course. This should be actioned by the manager. One staff member is an NVQ qualification assessor; another staff member has a social work qualification. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 24 The home has a supervision policy. Records informed the inspector that staff supervision takes place. Some staff supervision documentation was not easily accessible. Following the inspection the manager confirmed that he had reviewed the staff supervision procedure including improving the method of recording of it. This is positive. Records confirmed that some staff annual appraisals had taken place. The manager spoke of plans to ensure that all staff receive an appraisal. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 25 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. The manager needs to be registered with the Commission for Social Care Inspection. Arrangements are in place to ensure that quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home, but there could be some further development in this. 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, but some development in system checks are needed. EVIDENCE: 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 26 The manager has managed the care home for almost two years. He has many years experience of working with adults with mental health needs, and has managed a care home prior to taking up his present post. He has several qualifications relevant to his role as manager, and confirmed that he undertakes periodic training to maintain and update his skills and knowledge. He is currently undertaking a Registered Manager’s Award qualification, which he commenced sometime ago. The manager should complete this course. It was evident that the manager knows the people living in the care home very well. Records, staff, residents and observation during the inspection confirmed that the manager is motivated and pro active in ensuring that people living in the care home are supported and enabled to be as independent as they are able, and to lead a fulfilling and positive lifestyle. 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, particularly in regard to changes that he had instigated, since commencing his management role within the care home. It was evident that the manager aims to provide a quality service, which is resident led for the people living in the care home. The manager needs to apply for registration with the Commission for Social Care Inspection. This was a previous requirement. The manager spoke of commencing the process of registration. The home has an up to date recorded service development plan in regard to monitoring the quality of the service provided by the care home. A recent ‘away day’ for staff and residents enabled residents to communicate their thoughts and views about the care home, and of their ‘hopes and dreams’ for the future. The manager reported that questionnaires were in the process of being developed and would be supplied to residents and stakeholders (i.e. relatives, healthcare and social care professionals, and significant others) this year. This should be actioned by the manager. People using the service spoke of having the opportunity to attend regular resident meetings. Staff meetings also take place. There was evidence that policies and procedures are reviewed regularly. Certificates of worthiness in regard to the servicing of the electrical and gas systems were available for inspection. The gas system servicing was up to date but there needs to be evidence that an annual electrical portable appliance has been carried out (it was recorded as due 7/3/07), and there needs to be an up to date electrical installation service record, available for inspection. The home had a fire risk assessment but this was not comprehensive. The manager supplied the Commission with a copy of an up to date comprehensive fire risk assessment, and action plan following the inspection. Fire drills take 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 27 place as required. Records confirmed that staff receive fire training. Fire safety guidance is displayed within the home. Weekly fire checks are carried out. Fire precautions and emergency procedures are documented in the service user guide and statement of purpose documentation. Records confirmed that a fire safety professional had advised the home about evacuation processes as part of a fire safety risk assessment. This was a previous requirement, which was judged to have been met. The home has a health and safety procedure. Fridge and freezer temperatures are monitored. The care home has an accident reporting policy. Records confirmed that accidents are recorded. The certificate of employer’s liability insurance was displayed and up to date. 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 28 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 X 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 3 X 2 X 3 X X 3 X 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 29 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 37(c) Requirement CSCI must be informed of any event in the care home that adversely affects the well-being or safety of any resident and POVA procedures followed. Previous timescales 19/04/06 not met. The bathroom on the 1st floor (of 91) must be repaired to ensure that residents have access to a bathroom located close to their bedrooms. In regard to current staffing issues, recruitment for staff vacancies including the deputy manager post need to take place to ensure that the service is proactive in its provision of staffing in regard to its planning for meeting the needs and changing needs of people who use the service. The manager needs to supply the Commission for Social Care Inspection with evidence that all required recruitment and selection DS0000017519.V337558.R01.S.doc Timescale for action 01/07/07 2 YA24 23(2) 01/08/07 3 YA33 18 (1) 01/08/07 4 YA34 19(1) 18/07/07 89-91 Bessborough Road Version 5.2 Page 30 5 YA37 8(1) Care Standards Act Part II 11(1) 23 (2) 6 YA38 procedures have been carried out for one staff member, to ensure that the safety of residents is protected. It is required that the Manager applies for registration with the CSCI as the home’s Manager. Previous timescales 01/06/06 not met. • There needs to be evidence that an annual electrical portable appliance has been carried out (due date 7/3/07). • There needs to be an up to date electrical installation service record. 01/09/07 01/08/07 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 It is recommended that care plans continue to be improved, and that there is evidence that each resident is central to their plan of care and participates fully in this plan. Action taken by staff in response to incidents including any suspicion of abuse should be monitored closely. The manager should ensure that recently recruited care staff have the opportunity to achieve an NVQ qualification in care. The manager should complete the Registered Manager’s Award qualification. The manager should supply on an annual basis to residents and stakeholders (i.e. relatives, healthcare and social care professionals, and significant others) questionnaires about their views of the service. • 2 3 4 5 YA23 YA35 YA37 YA39 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 89-91 Bessborough Road DS0000017519.V337558.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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