Inspection on 12/12/05 for 94 Station Road

This inspection was carried out on 12th December 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

94 Station Road 27/11/06

94 Station Road 23/06/05

94 Station Road 05/01/05

94 Station Road 08/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

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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 94 Station Road Hendon London NW4 3SR Lead Inspector Tola Akinde-Hummel Unannounced Inspection 12th December 2005 09:05 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 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 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 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. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 94 Station Road Address Hendon London NW4 3SR 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) 020 8202 7621 020 8202 7621 Norwood Ravenswood T/A Norwood Miss Emma Jo Evelyn Davis Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2005 Brief Description of the Service: 94 Station Road is a registered care home accommodating five adults with learning disabilities The home is run by Norwood, a Jewish charity that operates mainly in the northwest area of London. The service accepts nonJewish people providing they understand and are prepared to live in a home that practices Jewish religion and observes the cultural rules. The home is a large two storey domestic premises that is well decorated and maintained. The communal areas are situated on the ground floor and consist of a lounge, kitchen/diner and conservatory. One service user has a ground floor bedroom with an adjoining toilet/shower room. The staff facilities and four other bedrooms are on the first floor with adequate bath/toilet facilities. The home has good access to shops and public transport facilities and is a short walk away from Hendon Central tube station. The stated aim of the home is to provide 24-hour care in a homely environment where the priority is given to the establishment of safe secure and nurturing relationships between service users and members of staff. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took approximately three hours to complete. The inspector was only able to speak to two service users briefly on arrival as they were on the way out to work and day centre. The other service users living in the home had already left for the day. There are no vacancies in the home. The manager, Ms Emma Davis was available throughout the inspection. At the time of inspection one other member of staff was in the building carrying out duties. The inspection included a tour of the building, examination of care plans, inspection of health and safety records, fire risk assessments, evidence medication storage and administration records, complaints and incidents records and examining staff files. The inspector with the manager examined the progress of requirements from the previous inspection. The inspector received five service user comment cards, two relative comment cards and one card from a reviewing officer. All these comment cards were positive about the service provided by the home. What the service does well: What has improved since the last inspection? The four requirements from the previous inspection have been met. The risk assessment requested has been forwarded to the commission within timescale. The manager arranged for each service user to be provided with fans during the hot spell in the summer, the shower in the bathroom has been repaired and the commission is receiving the monthly reports produced by the service manager. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 6 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. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 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 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,5 were examined at the previous inspection and were assessed as met. EVIDENCE: 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 9 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): 6,8,9 Service users care plans are amended as required to ensure personal, social and cultural needs are properly met. EVIDENCE: Three service users plans were inspected. These plans continue to be clear and easy to understand and have been updated where changes to the service users needs have been identified. Present changes include issues such as medication and behaviour. Amendments in plans are read and signed by staff members demonstrating that they understand and will implement any new changes for the benefit of service users. As described in the previous inspection report, service users continue to have a high level of autonomy within and outside of the home. Service users choose their meals, clothes and activities according to their preferences. Service users meetings take place in the home and the minutes are taken and typed by a service user reflect issue pertinent to service users. A previous requirement made to ensure that a risk assessment was completed has been undertaken and was sent to the commission as requested. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 10 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 11 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): 14,15 Service users are able to pursue their interests, maintain independence and develop relationships. EVIDENCE: The weekly activities plan based on service users preferences is available in the office for staff and service users. Service users continue to attend various classes to improve skills in subjects such as computers and languages. Service users comment cards express that they are happy with the activities available. The variety of activities available to service users has been improved since the previous inspection and demonstrates that a lot of thought is placed on meeting the interests of service users. One service user with an interest in horses is able to attend stables to assist with grooming once a week. The general diary in the home reveals a number of events planned for the festive season such as theatre trips and Chanukah parties. During the festive season service users have opted to spend some of the time with family members. All service users have positive relationships with people outside of the home this includes relatives and friends who are made welcome to the home. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 12 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): 18,20 Service users receive personal assistance as required. The home ensures that the medication is safely stored and administered. EVIDENCE: Service users in Station Road are very independent. There are however areas where some assistance is needed with personal care. This is recorded in detail in their care plans. Service users are encouraged to maintain their personal care with prompts by staff members. This is done in a sensitive manner taking into consideration the wishes of service users. Comment cards received from five service users, two relatives and one reviewing officer support this. Where possible following assessment, some service users are able to manage their medication. Staff ensure that all medication is taken as prescribed and repeat prescriptions are ordered. The home keeps a record of homely remedies. These are checked on a weekly basis. At the time of inspection, the medication records were correct and the temperatures of the medication cabinet satisfactory. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 13 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 Standards 22 and 23 examined at the previous inspection and were assessed as met. EVIDENCE: 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 14 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): 24,27, 94 Station Road is homely. This means service users who live there benefit from a comfortable, relaxed environment. EVIDENCE: 94 Station Road continues to be a warm and comfortable environment to live in. One relative highlighted this specifically in a returned comment card. The previous requirement to purchase fans for service users during the hot spell in the summer has been met. The communal areas in the home are well furnished and domestic in size and appearance. The kitchen area is separated according to Jewish tradition in meat and milk areas. Inspection of the bathroom showed that the previous requirement to repair the shower in the upstairs bathroom has been met. The downstairs shower room has conventional hand towels; there were no paper towels available. Paper towels are preferable to conventional hand towels to reduce the risk of cross infection. On the day of inspection, Station Road was generally clean and hygienic. One member of staff was carrying out household duties during the inspection. All 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 15 staff have cleaning duties in the home, which are detailed on the wall in the office. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 16 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, Service users have a staff team that are familiar with their needs and are well supported with training and supervision. EVIDENCE: Service users have had the benefit of a stable staff team. Presently there are six permanent staff members and two regular bank staff. Until more permanent staff members are employed, this system ensures that staff maintain relationships with service users and a consistent approach to care and support is applied. All staff are inducted in the Jewish way of life to ensure they understand service users cultural heritage and how to support this. Three staff files were examined during the inspection. Two of the three files contained the relevant information required in the standard such as application forms, references, criminal records bureau checks and terms and conditions of employment. One staff file does not have photo ID as required. This must be rectified. All staff are undertaking NVQ training. Presently two staff members have completed level 3 NVQ, one staff member has completed level 2, and one staff member is enrolled to undertake NVQ level 4. The staff files examined demonstrates that staff are regularly supervised and the supervision discussion includes service users, performance management, and training and development. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 17 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 18 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): 38,39,42 In general, 94 Station Road is run efficiently. This ensures service users safety. However the issue of food labelling must be addressed. EVIDENCE: The present manager has run 94 Station Road successfully for approximately three years. However the manager is due to move onto another Norwood Home in the New Year. The current deputy will take over management of the home. Service users and their relatives have already been advised of the change. Staff receive clear guidelines about the day-to-day running of the home and are supported to become familiar with the organisations policies and procedures. The manager has made some progress on the homes annual development plan. The short- term goals, which are ongoing and relate to increasing the independence and confidence, are met. The manager is trying to develop Norwood’s “ putting people first agenda” This programme will ensure that service users in Norwood homes are able to come together to have their say about all aspects of their care and support. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 19 The previous requirement to ensure that copies of the monthly unannounced Visits be sent to the commission has been met. During examination of the health and safety certificates in the home it was evident that the home meets its obligations in relation to health and safety. There was evidence from Norwood Head office that the Legionella, Gas Safety and emergency lighting checks had been carried out. However the original certificates sent to head office have not reached the home. These should be in the homes possession. Records of fire drills and fire tests are up to date. A member of staff and a service user completes this. An inspection of the kitchen noted that the extractor fan is greasy and requires cleaning. The inspection of the fridge reveals that food is not being labelled. This must be done to minimise any risk of food related illness to service users. The manager has recently updated the homes fire risk assessment this covers every area of the home and day and night fire procedures are in place. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 4 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 4 15 4 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 94 Station Road Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score X 3 3 X X 2 X DS0000010531.V265327.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 19(1) schedule 2(1) 13, 4, (c), 16, (2), (h) 16 (2) (g) Requirement The registered person must ensure that a photograph of an employee is placed on their personnel file. The registered person must ensure that the extractor fan in the kitchen is regularly cleaned to remove all dirt and grease. The registered person must ensure that all food is labelled to ensure consumption within the specified time and minimise the risk of food poisoning. The registered person must ensure that original up to date certificates for Gas safety tests and Legionella are kept in the home. Timescale for action 20/01/06 2. YA42 20/01/06 3. YA42 20/01/06 4. YA42 23 27/01/06 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 22 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 YA42 Good Practice Recommendations The registers person should consider introducing paper hand towels in the homes lavatories to minimise any risk of spread of infection. 94 Station Road DS0000010531.V265327.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. 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