Inspection on 21/09/06 for 93-95 Canning Road

This inspection was carried out on 21st September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

93-95 Canning Road 19/03/08

93-95 Canning Road 15/11/05

93-95 Canning Road 05/09/05

93-95 Canning Road 02/12/04

93-95 Canning Road 28/09/04

93-95 Canning Road 23/03/04

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 HCSN 93-95 Canning Road 93-95 Canning Road Wealdstone Middlesex HA3 7SP Lead Inspector Ms Sue Barker Key Unannounced Inspection 21st September & 3rd October 2006 13:30 HCSN 93-95 Canning Road DS0000017522.V307148.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 HCSN 93-95 Canning Road DS0000017522.V307148.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. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service HCSN 93-95 Canning Road Address 93-95 Canning Road Wealdstone Middlesex HA3 7SP 020 8424 8186 020 8424 0879 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 Mr Ross Hensman Care Home 6 Category(ies) of Learning disability (6) registration, with number of places HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: 93-95 Canning Road is a registered care home providing personal care and accommodation for a maximum of 6 adults aged 18-65 who have learning disabilities. The Registered Provider is the Harrow Consortium for Special Needs and the Responsible Person is Mr. Robert Seaman. The Registered Manager is Mr. Ross Hensman. Paddington Churches Housing Association (that takes responsibility for its maintenance) owns the building. The care agency is Harrow Mencap that employs the staff working in the care home. The home is located in a quiet residential road in Wealdstone on the outskirts of central Harrow. It is close to shops, pubs, transport and other community amenities. All the home’s bedrooms are single, and none have en-suite facilities. The home has a garden to the rear that is accessible through the lounge and kitchen The weekly placement fee for the service is determined by an assessment of the needs of the potential resident. Residents currently contribute a rent element towards the total cost of their placement. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 12.30pm on a warm afternoon in September. The Inspector attempted to commence the unannounced inspection earlier in the day but had not been able to gain entry to the care home and therefore called back later. The unannounced inspection was completed on 3/10/06 when the Inspector also met with the Registered Manager, Mr Hensman. The Inspector was pleased to meet and speak with most residents and staff on duty. Residents made the Inspector most welcome and kindly gave an insight into their lives in 93-95 Canning Road and future plans. The unannounced inspection additionally included observation/evaluation of care practice in the home, consideration of statutory records maintained and viewing the building. The Inspector additionally followed up requirements arising from the previous unannounced inspection. Residents spoke positively about their lives in 93-95 Canning Road and increasing levels of independence. The Inspector noted many positive developments in the care home since the last unannounced inspection that were focussed on residents achieving their desired choices and aspirations. There were 5 residents living in the care home at the time of the unannounced inspection. One resident was in hospital. The Inspector would wish to thank those in 93-95 Canning Road for their assistance and patience during the unannounced inspection and was made most welcome. What the service does well: Residents live in accommodation that is homely, spacious, light and bright. The aspirations and needs of potential residents are determined through their assessment process in 93-95 Canning Road. Residents take part in a number of individual activities that are determined through their choices and the care home’s care planning processes. Residents living in 93-95 Canning Road mostly have individual care plans that offer staff some guidance and advice on how to work them in a consistent manner. Residents living in 93-95 Canning Road were observed to be offered ordinary living choices by staff during the unannounced inspection. The home has completed some assessments of those risks identified in respect of individual residents living in 93-95 Canning Road though this work must be completed. Residents are independent in terms of their personal care tasks and receive support and promptings from staff. Staff support residents to access preventative healthcare services in the community. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 6 Residents living in 93-95 Canning Road access various facilities in the local community and beyond. Residents’ links with family and friends are documented within their care plan and this contact was evidence through inspection. Residents’ rights are respected in terms of their personal space and freedom of movement in the care home. Residents take responsibility for choosing their own meals in the care home with support from staff. Residents are supported by the care home’s protection of vulnerable adults arrangements. A team of support/care staff supports residents living in the care home. Staff presented as knowledgeable and approachable during the unannounced inspection. A full training programme is available for staff with the minimum requirements regarding NVQ Level 2 in care having been exceeded. Currently a full staff team is employed within the care home. Future staff recruitment will be based upon equal opportunities as well as ensuring the protection of residents. Residents benefit from living in a care home that has a registered manager. Mr Hensman has a clear vision for the care home based upon developing the individual needs and aspirations of residents. Residents’ opportunities for contributing their views and opinions are being developed in 93-95 Canning Road, with an ‘Annual Development Plan’ for the care home having been produced as is required. What has improved since the last inspection? What they could do better: Care plans and risk assessments are areas that the care home is still working on that must be completed for each resident. Residents’ medication is held safely in the care home, with appropriate records mostly maintained. The Inspector discussed the need to ensure that full records are maintained of medication administered to residents with staff support. Residents have access to the care home’s ‘Complaints Procedure’, though this information needs to be produced in formats that are appropriate and meet the needs of the residents living in 93-95 Canning Road. Residents live in small and homely accommodation. A number of new requirements regarding the building were noted that require attention. Residents live in an environment that was mostly found to be clean and hygienic. Two requirements were noted regarding the laundry. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 7 Residents’ health and safety are promoted and protected in the care home, although 3 requirements arose regarding the extent of this work 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. HCSN 93-95 Canning Road DS0000017522.V307148.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 HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The aspirations and needs of potential residents are determined through the assessment process in 93-95 Canning Road. EVIDENCE: The Inspector discussed the process whereby potential residents are assessed for a placement in the care home, with Mr Hensman. The assessment is carried in conjunction with the care home and includes a written initial assessment that includes input from the potential resident regarding their views, skills and current situation. The Inspector viewed an example of the assessment documentation. Potential residents are referred to the care home by the local authority. Transition plans are developed as part of the process of the potential resident moving into the care home. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents living in 93-95 Canning Road have individual care plans that offer some guidance and advice on how to work them in a consistent manner. Care plans are, however, still being developed. This work must be completed. Residents living in 93-95 Canning Road were observed to be offered ordinary living choices by staff during the unannounced inspection. The home has completed some assessments of those risks identified in respect of individual residents living in 93-95 Canning Road though this work must also be completed. EVIDENCE: The Inspector viewed a sample of residents’ care plan documentation and noted that staff had done much work to create new care plans. These were to replace those previously in use. Care plans showed evidence of their having been developed in conjunction with residents. Work on the care plans was not, however, completed. Some aspects of the care plans were written in the 1st person and included the resident’s input and indication of their personal choices. One resident had signed for parts of their care plans. The Inspector HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 11 discussed with Mr Hensman the possibility of care plans being written more in the 1st person where they are clearly indicating their choices and preferences. Care plans included different areas of the resident’s life including leisure and social opportunities, personal care, communication and health. The completed areas of the care plans presented as comprehensive. Within the sample of care plans viewed there was evidence of attention to resident’s individual cultural and diversity needs and choices. There was indication that care plans are to be updated on a monthly basis in conjunction with the resident, though no such reviews were recorded as taking place. It must be ensured that work on the care plans is completed as quickly as possible. Some residents kindly let the Inspector know who their key workers from within the staff team were. The Inspector observed residents being supported by staff to undertake ordinary living tasks. Staff kindly spoke extensively to the Inspector about the individual residents’ needs and choices. Residents kindly let the Inspector know about the things that they like doing, what they had done that day and their plans for the future. Some residents were shortly to go on holiday with staff support. Residents were observed making choices about whether to go out. The Inspector viewed a range of residents’ risk assessment documentation and noted that some recent updating had been taking place. This included the areas of risk identified and level of risk. This work was not completed. It must be ensured that individual written risk assessments are in place in respect of those areas of risk identified for individual residents. Risk assessments must be kept under review as part of the care home’s care planning arrangements. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents take part in a number of activities that are determined through their choices and the care home’s care planning processes. Residents living in 93-95 Canning Road access various facilities in the local community and beyond. Residents’ links with family and friends are documented within their care plan and this contact was evidenced through inspection. Residents’ rights are respected in terms of their personal space and freedom of movement in the care home. Residents take responsibility for choosing their own meals in the care home with support from staff. EVIDENCE: Residents were at their day placements/college when the Inspector arrived in the care home and returned home later in the day. Some residents kindly let the Inspector know where they had been and things that they had been doing that they particularly enjoy. Most residents go out into the community independently. Three residents kindly spoke to the Inspector about the HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 13 changes that occurred in their lives as a result of their going out and travelling independently; with the new options and choices that they consequently enjoyed. One resident kindly let the Inspector know what they enjoy watching on television. Staff supported one resident to attend a sports club on the evening of the unannounced inspection. Other residents let the Inspector know about the clubs that they attend in the evening. Some residents spoke about their forthcoming holiday, which they were looking forward to. Staff on duty were supporting residents to pack for their forthcoming holiday. Staff on duty spoke to the Inspector about the individual equalities and diversity needs of residents. The Inspector gathered from residents that they enjoy flexible routines in the care home and have individual routines. The Inspector observed a resident choosing what they wanted to eat. Another resident kindly showed the Inspector their drawers of food in the fridge and freezer. Staff spoke to the Inspector about residents’ individual family contacts. Such contacts are included within their care plans. A record of visitors to the care home is maintained as required. The Inspector observed staff knocking on residents’ door before entering. Residents were addressed by their first names. Staff were observed in conversation with residents. Discussion was around a range of issues. Some residents were observed letting staff know what they had done during their day. The Inspector observed residents unlocking their bedroom doors on arrival home. Residents were observed moving around the care home freely. Residents let the Inspector know that they would be choosing what to eat for dinner. No house menus were displayed in the care home for residents. The food cupboards in the kitchen were inspected and contained ranges of store cupboard foods. Residents have their own spaces for food in the fridges and freezers. Residents were observed choosing what they want to eat for dinner and then were supported by staff to cook it. One resident kindly let the Inspector know type of takeaway they enjoyed eating. Mr Hensman advised the Inspector that menu planning arrangements in 93-95 Canning Road had changed whereby residents are now supported to plan their individual menus on a weekly basis and will be supported by staff to buy the food and then prepare it in the care home. Supplies of communal store cupboard foods are also purchased for the care home. The Inspector observed that residents’ weights are monitored on a monthly basis with a record maintained. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are independent in terms of their personal care tasks and receive promptings from staff. Staff support residents to access preventative healthcare services in the community. Residents’ medication is held safely in the care home, with appropriate records mostly maintained. The Inspector discussed the need to ensure that full records are maintained of medication administered to residents with staff support. EVIDENCE: Residents living in 93-95 Canning Road carry out their own personal care tasks independently and are mainly prompted by staff. Residents kindly spoke to the Inspector about how they spend their time in the care home both during the week and at weekends. It was gathered that that residents enjoy a flexible lifestyle. Some residents were choosing their own clothes that they wanted to take away on holiday with them. Residents have named key workers from within the staff team. Some residents kindly let the Inspector know who their key workers were. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 15 Staff document residents’ attendance at preventative healthcare checks, with details of any outcomes and recommendations. This includes dentist, optician and GP. Staff diary residents’ forthcoming medical appointments. The Inspector viewed information and guidance for staff on a medical condition suffered by one resident with written guidelines for administration of PRN medication. This was, however, not in place in respect of all medication prescribed for residents on a PRN basis as is required. The Inspector viewed the care home’s medication storage, administration and recording systems. Staff let the Inspector know that residents are moving to a position where they self-medicate. Medication is supplied to the care home by its contracted pharmacist and is stored within a locked cupboard in the care home. Two members of staff record when they have administered medication to residents, where possible. The Inspector noted some earlier gaps in the recording of medication administered to residents by staff. This was discussed with Mr Hensman. The Inspector noted that the care home’s pharmacist had visited the care home on 11/5/06 and offered staff medication training. Medication training is available to staff as part of the ‘Harrow Mencap Core Training programme’. HCSN 93-95 Canning Road DS0000017522.V307148.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 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 adequate. This judgement has been made using available evidence including a visit to the service. Residents have access to the care home’s ‘Complaints Procedure’, though this information needs to be produced in formats that are appropriate and meet the needs of the residents living in 93-95 Canning Road. Residents are supported by the care home’s protection of vulnerable adults arrangements. EVIDENCE: The Inspector viewed a small ‘Complaints Procedure’ leaflet displayed on a notice board in the kitchen. The Registered Provider had produced this and it referred to the Registered Provider, care agency and NCSC. The policy included timescales for response and contact details for the local Commission for Social Care Inspection office. This needs amendment to include the correct details for the Commission for Social Care Inspection. Contact details for the local Commission for Social Care Inspection office are displayed separately in the kitchen. The policy was produced in small typed A4 folded format. The Registered Provider must consider the production of information about how to make a complaint in formats that are appropriate for residents. A record is maintained of complaints that have been made to the care home. Two complaints were logged as having been received in September 2006. Mr Hensman updated the Inspector on his progress on investigating these complaints. Some residents kindly let the Inspector know which members of staff they would talk to in the event of there being something wrong. A ‘Protection of Vulnerable Adults’ policy was displayed in the home’s office. Harrow Mencap had produced this. Staff confirmed that they had undertaken HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 17 training in Protection of Vulnerable Adults. Staff hold money on behalf of residents. The Inspector observed staff checking the sums held against the record maintained of outgoings and incomings. This was correct in respect of those examples observed. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in small and homely accommodation. A number of new requirements were noted that require attention. Residents live in an environment that was mostly found to be clean and hygienic. Two requirements were noted regarding the laundry. EVIDENCE: The Inspector viewed the communal areas of the building and 2 residents kindly invited the Inspector to view their bedrooms. Residents spoke positively about the building that they live in. One resident had got their bedroom set out in the way that they liked. Another resident was to discuss some suggestions that they had regarding the building with the Registered Manager. The premises largely presented as bright, airy, clean and free of offensive odours. Windows were open in the building to ventilate on what was a warm day. There have been some changes to the building since the Inspector visited last, including new flooring in the first floor bathroom. A number of requirements arising from the last inspection have not been complied with and some additional requirements were noted during this inspection that are listed below. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 19 The care home laundry is located on the first floor of the building. It contained a washing machine and dryer and both machines were observed to be working. The laundry flooring and walls are of impermeable materials although there remains extensive cracking on the wall to the right of the window. The sink unit in the laundry is in a poor state of repair with exposed chipboard. This requires repair or replacement. The laundry flooring has been replaced. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A team of support/care staff supports residents living in the care home. Staff presented as knowledgeable and approachable during the unannounced inspection. A full training programme is available for staff. Currently a full staff team is employed within the care home. Future staff recruitment will be based upon equal opportunities as well as ensuring the protection of residents. EVIDENCE: During the unannounced inspection, the Inspector observed staff in conversation with residents as well as supporting them with their ordinary living choices. Some residents kindly let the Inspector know about which members of staff they particularly talk to. A pictorial representation of the staff rota is displayed in the kitchen for residents. The Inspector heard residents asking staff about who was on duty on the following day. Staff on duty talked to the Inspector about resident’s individual cultural and diversity needs and how these were being accommodated. Staff presented as knowledgeable concerning the individual needs of each resident. The Inspector was advised that of the 5 support staff employed in 93-95 Canning Road, 4 hold the required NVQ in care training. This exceeds the minimum requirements. HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 21 Mr Hensman advised the Inspector that no staff recruitment had been conducted since the last statutory inspection of the care home. Indeed a full staff team was in place though some staff vacancies were shortly arising. The Inspector discussed with Mr Hensman requirements in respect of staff recruitment and the various checks that must be carried out on applicants for employment in the care home. Mr Hensman stated that residents are involved in any staff recruitment occurring in the care home. The Inspector viewed detail of the ‘Harrow Mencap Core 06-07 Training Programme’ for staff employed in the care home. This presented as comprehensive and included infection control, involving service users and equal opportunities and anti-discrimination. The Inspector additionally viewed evidence of the care home’s induction and foundation training. An individual record of the training undertaken by staff is maintained. HCSN 93-95 Canning Road DS0000017522.V307148.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from living in a care home that has a registered manager. Mr Hensman has a clear vision for the care home based upon developing the individual needs and aspirations of residents. Residents’ opportunities for contributing their views and opinions are being developed in 93-95 Canning Road, with an ‘Annual Development Plan’ for the care home having been produced as is required. Residents’ health and safety are promoted and protected in the care home, although 4 requirements arose regarding the extent of this work. EVIDENCE: Mr Hensman has achieved registration with the Commission for Social Care Inspection since the last unannounced inspection. Mr Hensman let the Inspector know that he was undertaking the Registered Managers’ Award as is required. Mr Hensman discussed with the Inspector his vision for 93-95 Canning Road. This included empowering residents to achieve their individual HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 23 goals and aspirations. The Inspector discussed with Mr Hensman the need to ensure that the care home is staffed at all times. Mr Hensman responded that this only rarely occurred, but was working on cover arrangements in such an eventuality, with an appropriate risk assessment having been carried out. The Inspector viewed a copy of this assessment. The Inspector was kindly passed a document entitled ‘93-95 Canning Road Annual Development Plan’ for 2006-07. This included input from residents and objectives and plans for the coming year. The Inspector viewed up to date Certificates of Worthiness in respect of the care home’s electrical fire detection system, fire fighting equipment, gas appliances and system and electrical hard wiring. The annual testing of the care home’s portable electrical appliances and in respect of the risk of Legionella must be carried out with copies of Certificates of Worthiness forwarded to the Commission for Social Care Inspection. The Inspector viewed a Fire Risk Assessment dated 11/4/05. It must be ensured that this assessment is reviewed annually. Three fire drills/practices are recorded as having been carried out in the last year within 93-95 Canning Road. It must be ensured that 4 fire drills/practices are carried out a year with the outcome and those attending recorded. Fire bells are tested on a weekly basis with the last recorded test occurring on 18/9/06. Staff record the temperatures of the fridges and freezers within the care home, mostly on a daily basis. It must be ensured that this is carried out on a daily basis. Staff maintain a record of accidents that occur in the care home. Safety information is available for staff employed in 93-95 Canning Road. There were 2 Certificates of Public Liability displayed in the care home (one provided by the Registered Provider and the other by Harrow Mencap), the certificate provided by the Registered Provider had expired on 11/7/06. Mr Hensman was to obtain this document from the Registered Provider. It must be ensured that there is a current Certificate of Public Liability displayed in the care home. HCSN 93-95 Canning Road DS0000017522.V307148.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 x 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 25 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 Standard YA6 YA9 Regulation 15 13 Requirement It must be ensured that work on residents’ care plans is completed as quickly as possible. It must be ensured that individual written risk assessments are in place in respect of those areas of risk identified for individual residents. Risk assessments must be kept under review as part of the care home’s care planning arrangements. A full record must be maintained of medication administered to residents by staff. (Previous timescale of 15/01/06 not met) Ensure that written guidelines for administration of PRN medication are in place in respect of all medication prescribed for residents on a PRN basis. The Registered Provider must consider the production of information about how to make complaints in formats that are appropriate for residents. Replace damaged shower seat in ground floor shower room. (Previous timescale of DS0000017522.V307148.R01.S.doc Timescale for action 13/11/06 13/11/06 3 YA20 13 13/11/06 4 YA20 13 13/11/06 5 YA22 22 13/12/06 6 YA24 23 13/11/06 HCSN 93-95 Canning Road Version 5.2 Page 26 15/01/06 not met) 7 YA24 23 The grouting in the ground floor shower room must be replaced where stained. (Previous timescale of 15/02/06 not met) The first floor bathroom and toilet require redecoration. (Previous timescale of 15/02/06 not met) Black mould on the walls and ceiling of the first floor bathroom must be removed. (Previous timescale of 15/02/06 not met) Repair the broken corner kitchen cupboard door Deep clean ground floor hallway carpet, as it is stained. Redecorate the ground floor toilet. The lower kitchen cupboard edges are damaged and require repair in order to ensure that the cupboard surfaces remain impermeable. The sink unit in the laundry is in a poor state of repair with exposed chipboard. This requires repair or replacement. The laundry walls require repair and redecoration as are extensively cracked in the area to the right of the window. (Previous timescale of 29/01/06 not met) It must be ensured that there is a current Certificate of Public Liability insurance displayed in the care home. The annual testing of the care home’s portable electrical appliances and in respect of the risk of Legionella must be carried out with copies of Certificates of Worthiness forwarded to the Commission for Social Care DS0000017522.V307148.R01.S.doc 03/12/06 8 YA24 23 03/12/06 9 YA24 23 13/11/06 10 11 12 13 YA24 YA24 YA24 YA24 23 23 23 23 13/11/06 13/11/06 03/12/06 03/12/06 14 YA30 23 13/12/06 15 YA30 23 03/12/06 16 YA42 25 13/11/06 17 YA42 13 03/12/06 HCSN 93-95 Canning Road Version 5.2 Page 27 Inspection. 18 19 YA42 YA42 23 13 The Fire Risk Assessment must be reviewed annually. It must be ensured that the temperatures of the fridges and freezers within the care home are tested on a daily basis, with a record maintained of outcomes. 13/11/06 13/11/06 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 Standard Good Practice Recommendations HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 28 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 HCSN 93-95 Canning Road DS0000017522.V307148.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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