Inspection on 20/11/07 for Dimensions 54 Beechcroft Gardens

This inspection was carried out on 20th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dimensions 54 Beechcroft Gardens 04/04/06

Dimensions 54 Beechcroft Gardens 16/09/05

Dimensions 54 Beechcroft Gardens 04/04/05

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 Adepta 54 Beechcroft Gardens 54 Beechcroft Gardens Wembley Middlesex HA9 8EP Lead Inspector Judith Brindle Key Unannounced Inspection 20th November 2007 08:15 DS0000062638.V351702.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 DS0000062638.V351702.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. DS0000062638.V351702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adepta 54 Beechcroft Gardens Address 54 Beechcroft Gardens Wembley Middlesex HA9 8EP 020 8904 8258 020 8343 8876 sotalabi@adepta.org.uk www.pentahact.org.uk Adepta 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) Olufunmilayo Sarah Talabi Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000062638.V351702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th April 2006 Brief Description of the Service: 54 Beechcroft Gardens is a is a registered care home providing personal care, and accommodation for up to 3 adults who have a learning disability. The care home is a detached 3-bedroom bungalow located in Wembley Park, close to a variety of shops, health, social and leisure services, and other amenities. Bus and train public transport facilities are in close proximity to the home. There is parking for two to three cars on the forecourt of the care home. A well maintained enclosed garden is located at the rear of the property. The local health authority owns the property and Adepta provides the care and support for the people using the service. Documentation/information about the care home is accessible to residents and to visitors. Fees, including additional charges vary according to the individual needs of residents. The range of fees is £1350- £2000. The fee contribution paid by the residents is documented in their contract/statement of terms and conditions. DS0000062638.V351702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in November 2007. There were no vacancies at the time of the inspection. During the inspection I was pleased to meet and talk with all the residents. Due to the communication needs of some of the residents, observation was a significant tool used during the inspection. Staff were also spoken with during the inspection, and all were very helpful in supplying documentation, and information requested by the me. Documentation inspected included, resident’s care plans, residents’ financial records, risk assessments, staff training records, and some policies and procedures. The registered manager was present during most of the inspection. The inspection also included a tour of the house, and two residents kindly showed me their bedrooms. Registered services are required to supply Annual Quality Assurance Assessment (AQAA) documentation, to the Commission for Social Care Inspection (CSCI). This consists of information from the owner or registered manager about the service provided by the care home and includes plans for developing and improving this service. Prior to this unannounced key inspection the CSCI had not received the (AQAA) document within the timescales given, but the registered manager supplied the documentation to the CSCI shortly after this inspection. The AQAA record had been completed fundamentally, but could have been further developed in some areas, particularly in regards to plans for improvement within the next twelve months. There is reference to this AQAA information within this report. Assessment as to whether the requirements from the previous inspection had been met also took place during the inspection. Staff and inspection of records confirmed that these had been met by the service. 26 National Minimum Standards, including key National Minimum Standards for adults were inspected during this inspection. The inspector thanks all the people living in the care home, and the staff for their assistance during the inspection process. What the service does well: DS0000062638.V351702.R01.S.doc Version 5.2 Page 6 The care home has a very welcoming atmosphere. Residents live in a homely environment, with quality furnishings, and decoration that is attractive, and meets the varied needs of the people using the service. The registered manager is experienced, and very motivated in ensuring that a quality service is provided to all the people using the service. She ensures that there is liaison with healthcare professionals, and other specialists as and when needed by the residents. Staff receive varied and appropriate training to ensure that they are skilled in carrying out their roles and responsibilities. Observation and talking to staff indicated that staff had knowledge and understanding of each of the resident’s needs, and that interaction between staff and people using the service, was sensitive and respectful. A resident said that ‘they (staff) look after us’. People using the service are involved in the process of selection of new staff. The care home is located close to a variety of amenities and public transport facilities, and healthcare facilities. What has improved since the last inspection? What they could do better: The format of the care plans and some other documentation could continue to be further developed to improve their accessibility to the residents who have communication needs including difficulty in reading. Risk assessments could be further developed to ensure that it is evident that people using the service are supported to take risks as part of an independent lifestyle. The registered manager should complete the NVQ (National Vocational Qualification) level 4 course. Please contact the provider for advice of actions taken in response to this DS0000062638.V351702.R01.S.doc Version 5.2 Page 7 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. DS0000062638.V351702.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 DS0000062638.V351702.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective people using the service have the information that they need to make an informed choice about where to live, and prospective resident’s needs are assessed to ensure that the service is confident that it can meet that person’s needs. EVIDENCE: I was informed that all the residents have received a documentation ‘pack’ containing information about the service, the owner, and some significant procedures particularly relevant to the residents. The manager reported that there was an up to date service user guide, which she was unable to access during the inspection, but she supplied the Commission for Social Care Inspection, with a copy of this documentation following the inspection. This is a comprehensive informative document, which included some pictures, including pictures of the staff that work in the home. I was shown a resident handbook and the statement of purpose, which are informative about the service provided by the care home. Other formats of documentation that make the information more accessible to the residents, meeting their individual capacity needs, particularly in regard to communication and reading needs, was discussed with the manager and a senior staff member. A DVD and/or CD format were some considerations. The manager spoke of plans to further develop more accessible formats. DS0000062638.V351702.R01.S.doc Version 5.2 Page 10 There have been no new admissions to the care home for over two years. Two of the residents have lived in the home for many years. A staff member spoke of the admission process, which is also documented in the statement of purpose. This includes a referral from Local Authority health or social services, and the prospective resident then receives an assessment from the manager or and/or other person competent in the assessment process. There was evidence in each care plan that residents receive a comprehensive assessment prior to being admitted to the home, which includes participation from the prospective service user and family members/significant others. The relevant Local Authority funding authority care manager also assesses the needs of prospective residents. Staff confirmed that prospective residents would be supported, and encouraged to visit the home several times to meet the other residents, and the staff and to ‘test drive’ the home to ascertain as to whether the care home meets their needs and aspirations. DS0000062638.V351702.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): Standard 6,7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. All residents have a plan of care, in which resident’s assessed and changing needs, and personal goals are reflected. Residents are supported and encouraged to make decisions and choices, and to take risks as part of an independent lifestyle. EVIDENCE: All the residents have a care plan. The care plan information was included in large bulky files where not all information was easily accessible. The staff should consider reviewing these files and archiving non up to date information. Each care plan included a profile of the resident, and assessment information with a number of documented identified needs, including health, personal care, behaviour, and religious/cultural needs. The care plans recorded evidence that a comprehensive review of the care plan had been carried out every six months with goals identified, and some of which reviewed. Some goals identified during the reviews are included in the care plans, but others are not. These include some activity/social needs. This was discussed with the DS0000062638.V351702.R01.S.doc Version 5.2 Page 12 manager, who spoke of plans to improve the care plan format to develop its accessibility, to ensure it is more evident that residents are fully involved in their care plans, and agree with their content, and that they be more of a working document, and be more ‘person centred’ (i.e. it being evident that the care plan is central to the resident). It was apparent that the resident, relatives/significant others, senior staff, the key worker, and care manager from the relevant funding Local Authority were invited to the care plan reviews. Staff are all fully involved in the care plans and in the review process. A staff member spoke of reading the care plans regularly to keep up to date with any changing needs. Recorded staff guidance in regard to meeting resident’s needs was documented. This included guidance regarding behaviour that might challenge the service from residents. The residents’ progress is reviewed on a monthly basis, and comprehensive ‘daily’ records of each resident’s progress are documented. During the inspection I spent a significant amount of time with residents, and staff. Staff were heard to offer residents choices, and were observed to be sensitive regarding their interaction with residents. Records and a resident confirmed that the times for getting up and going to bed were flexible. I was informed that all the residents have an advocate, who attends the individual care plan review meetings, and visits them regularly. Staff reported that the advocate supported the residents to complete feedback questionnaires about the service provided by the home. All residents have a key worker. All the residents have their own bank accounts. They keep their bank books in their bedrooms in a locked container. Some financial items are stored in the office safe. I was informed that the people using the service are all signatories to their own bank/building society accounts. The financial records and balances of all the residents’ monies were inspected. Records confirmed that appropriate records of incoming payments and expenditure were documented. I was informed that staff on each shift ‘checks’ resident’s monies. This was observed during the inspection. It was evident that residents were receiving their entitled personal allowances. A resident spoke of choosing and buying her own toiletries with her own money. She kindly showed me some clothes that she had bought. There was some evidence of risk assessments, which included health and safety, and ‘challenging’ behaviour risk assessments. An assessment in regard to developing a pressure sore had been documented, and concluded that there was a risk. There should be a risk assessment with guidance developed from this. There was evidence of some risk assessments having been reviewed, but not all. Annual Quality Assurance Assessment (AQAA) documentation informed me that the home plans to develop resident’s participation in the risk assessment process, and to improve the format of this documentation. This is positive. There should be a risk assessment in place in regard to staff working in the care home on ones own (see Staffing outcomes section). DS0000062638.V351702.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13, 14, 15, 16 and 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and in the development of their life skills. Social, educational, cultural and recreational activities meet individual expectations. Meals are varied and wholesome, and meet the cultural/religious needs of people living in the care home. EVIDENCE: People using the service have an individual activity plan. This clearly records activities that take place upon a daily basis, and include community based leisure pursuits. It was evident that the care home understands the importance of enabling people using the service to achieve goals, follow their interests, and be integrated into community life. A resident spoke of choosing activities and of enjoying the ones that she participated in which included participation in independent living skills, such as cleaning, cooking. During the inspection, people using the service were observed with staff support to DS0000062638.V351702.R01.S.doc Version 5.2 Page 14 participate in everyday living skills, and a resident attended a day resource centre. I was informed by the manager that due to changes in the accessibility of some day centres, she and the staff team were supporting residents to access other leisure pursuits in the local community including going to the local library, other 1-1 activities. A resident said that ‘I go to church on Sunday’. Other activities include music, and aromatherapy sessions. Forthcoming community events including a Carol service at the Local Authority Town Hall were displayed on a notice board, and puzzles, music systems; magazines and board games were accessible. The manager spoke of a resident’s enjoyment and skill at completing jigsaw puzzles. A resident said that she ‘goes to church’. Staff informed me that two residents regularly attend church. A resident spoke of her enjoyment of a holiday that she had had recently. She said ‘I like Butlins’. Annual Quality Assurance Assessment (AQAA) documentation informed me that the care home is very aware of the equality and diversity needs of people using the service, and ensuring that staff values are not imposed upon residents. Staff confirmed that this is evident in regard to resident’s individual activity needs and preferences. The visitor’s book confirmed that there were many visitors to the care home. It was apparent that the home supports residents to develop and actively maintain relationships with family and friends. I was informed by staff that people using the service have varied contact with relatives/significant others. A staff member described that arrangements made and support given to a resident following a bereavement. I was informed that a resident was planning to stay with a relative at Christmas, and another had plans for an imminent birthday celebration. A resident spoke of her contact with family members. The home has a telephone which is accessible to people using the service. Annual Quality Assurance Assessment (AQAA) documentation informed me that the care home values opinions and views about the service from all stakeholders including relatives, advocates and others, and that the home is aware of the positive effects of encouraging family/friends involvement (if agreed by the person using the service) in the care home. The home has a menu. This is displayed in the kitchen. Fresh fruit was accessible in the kitchen, and in the sitting/dining room. A resident spoke of participating in cooking, and said ‘I like the food’. Two people using the service made themselves cups of tea as and when they wished during the inspection. A resident prepared her own breakfast, and spoke of choosing what to eat. Food eaten by residents is recorded. I was informed that a resident chooses to eat her meals in her bedroom. This should be documented in the care plan. DS0000062638.V351702.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18,19 and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s personal support needs are met in the way they prefer. Physical, emotional and healthcare needs are met, and the principles of respect, dignity and privacy are put into practice. Medication is stored and administered safely EVIDENCE: Personal healthcare needs including specialist health needs are recorded in the individual care plans pf people using the service. It was evident during the inspection that staff respected resident’s privacy. Records confirmed that residents have their health needs monitored, and have access to care and treatment from a variety of healthcare professionals. These include GP appointments, optician, dentist, chiropody care and treatment. Hospital appointments are attended as and when needed by people using the service. Residents as needed, access additional specialist support and advice, including psychologist support. A resident told me that she had received a flu vaccination on the day before the inspection. DS0000062638.V351702.R01.S.doc Version 5.2 Page 16 Care plans inspected included up to date individual health action plans. There should be evidence that these are updated following changes in health needs of the resident, for example a resident’s reviewed hearing needs should be included in this documentation. Annual Quality Assurance Assessment (AQAA) documentation informed me of the variety of ways that the care home supports a resident who has mobility needs to be as independent as possible. The home has a medication procedure. This document was produced by the previous owner. There should be evidence of an up to date medication procedure with correct information about the name of the present owner. The medication storage and administration systems were inspected. Medication is stored securely. The home a system of dossette boxes that are packed by a pharmacist on a weekly basis. There were no gaps in recording on the medication administration charts. Records of medication received by the home and returned to the pharmacist were available for inspection. Staff informed me that the pharmacist audits the medication systems on a six monthly basis. Staff and records confirmed that staff receive medication training, which included a medication training session from the pharmacist. DS0000062638.V351702.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 and 23 People who use this service experience good outcomes in this area This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and handled appropriately, and residents are protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints procedure. This was displayed in the communal area of the home, and is recorded in the service user guide in pictorial and written format. Complaints were recorded and investigated appropriately, within 28 days. Records confirmed that residents were knowledgeable regarding communicating concerns/complaints, to senior staff and others, including the Local Authority, as and when required, and that staff took these seriously. Annual Quality Assurance Assessment (AQAA) documentation informed me that the service supports residents and others to communicate concerns and/or complaints, and that residents have significant opportunities to raise any concerns during care plan review meetings and at other meetings. A resident spoke of speaking to the manager if she had a complaint/concern. The care home has a protection of vulnerable adults policy/procedure including the Local Authority safeguarding adults procedure. Staff were clear about the appropriate reporting and recording procedures to be followed if informed of a suspicion or allegation of abuse. Records and staff confirmed that staff have received protection of vulnerable adults training. The resident’s handbook includes some information regarding abuse awareness. DS0000062638.V351702.R01.S.doc Version 5.2 Page 18 Annual Quality Assurance Assessment (AQAA) documentation also informed me that the home is aware of the need to ensure that relevant Care Managers, and others are informed of significant complaints and/or safeguarding adults issues, without delay. DS0000062638.V351702.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is accessible, safe, homely, clean and comfortable. The premises are suitable for the care home’s stated purpose. Resident’s bedrooms are individually personalised, and meet their individual needs. EVIDENCE: The home is a bungalow, which is in keeping with other houses in the locality. I was informed that the front external walls had recently been painted. There is parking for two to three vehicles on the forecourt. The care home has homely features, with pictures and photographs displayed. Furnishings and fittings were judged to be of quality. There is a large fish tank in the sitting room area of the home. Staff spoke of residents enjoying observing the fish. A large television is located in the communal area. The dining area has seating for five or six people. The home is warm, clean and free from any offensive odours. The home was decorated with festive DS0000062638.V351702.R01.S.doc Version 5.2 Page 20 decorations. A resident spoke of looking forward to Christmas, saying ‘I ‘m happy its soon Christmas’. Staff spoke of the planned seasonal celebrations. The carpet in the communal sitting room is stained in some areas and needs to be cleaned or replaced. The home has handrails, ramps, and grab rails within the home, and the layout of the home, as a bungalow is particularly suited for those with mobility needs. The garden is enclosed and well maintained. There is accessible seating for residents and visitors. Staff spoke of their having been several barbeques held in the garden during summer months. A resident spoke of spending time in the garden. A rose bush, (chosen by a person using the service) has been planted as a memorial to a relative of a resident who died recently. Residents were observed to move freely within the home, and chose when they wished to be on their own in their bedroom. Two residents kindly showed me their bedrooms. These were personalised with a variety of ornaments, pictures, photographs, and other personal possessions including their own televisions. A resident had a mini fridge in her room. A resident confirmed that she chose the colour of the bedroom’s décor. One of the bedrooms had an ensuite toilet. The curtain in one resident’s room should be fixed where it is hanging down. The home is clean and odour free. Soap and hand towels were located in the bathrooms/toilets inspected. The home has an infection control policy/procedure. Staff were observed to wear protective clothing as, and when needed. Records confirmed that there was infection control training planned for staff. DS0000062638.V351702.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33, 34, 35 and 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities, and residents are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: There was one staff member on duty at the commencement of the inspection, who had completed a ‘sleep in’ duty the previous evening/night. Another member of staff came on duty at 9am to accompany a resident to a day resource centre. The staff rota was available for inspection. There is generally one member of staff on duty, but a second staff usually works for several hours during the day to enable residents to take part in activities and to attend various medical and hospital appointments. There should be a risk assessment in place in regard to staff working in the care home on ones own (see Individual Needs and Choices outcome section). The manager is on duty during the week, and she spoke of recently adapting her working hours to working later in the afternoon to meet resident’s needs. She confirmed that the number of staff on duty is reviewed regularly, and that extra staff could be on duty in response to the changing needs of residents. The registered DS0000062638.V351702.R01.S.doc Version 5.2 Page 22 manager should ensure that she regularly reviews staffing needs during the day to ensure that there are enough staff on duty to enable residents to participate in 1-1 community activities particularly in regard to some day resource sessions having been discontinued. There were pictures of the staff on duty displayed in the sitting/dining room. It was evident that staff communicate positively amongst themselves, and with residents. A staff communication book recorded a number of entries from staff, and confirmation that messages had been read. Regular staff team meetings take place. The home has a recruitment and selection policy/procedure. Three staff personnel files were inspected. This documentation included evidence that required and appropriate recruitment procedures had been carried out. The manager informed me that people using the service are involved in the process of selection of new staff. This is positive. A staff member confirmed that she had completed an induction programme, which was comprehensive and informative regarding her role and responsibilities as a care staff member. Staff spoke of having received ‘lots’ of training appropriate and relevant to their roles and responsibilities. This included health and safety, moving and handling, protection of vulnerable adults training, 1st Aid, fire, food and hygiene. Among other training included diabetes training, healthy eating, ‘person centred planning’, loss and bereavement, team building, and communication training. Certificates of staff training were available for inspection. Records confirmed that a staff member was participating in a training session on the day of the inspection. The manager spoke of having ‘booked’ a new member of staff on a variety of training courses that take place in the forthcoming months. I was informed that three staff (plus two regular temporary staff) have completed NVQ (National Vocational Qualification) level 2 in care. A staff member spoke of having achieved NVQ level 3 in care within a relatively short period of time, and spoke of how this course had been of benefit in regard to her role and responsibilities as a care staff member. Staff spoke of receiving regular 1-1 supervision. Records confirmed that staff appraisals are carried out. DS0000062638.V351702.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent, and experienced to run the care home, and effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision for people using the service by the care home. So far as reasonably practicable the health safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has worked for several years with residents who have a learning disability, and has managed 54 Beechcroft Gardens since 2002. She has been in the process of completing an NVQ (National Vocational Qualification) level 4 care management training for over two years and should complete this course. The manager spoke of ensuring that she updates her knowledge, and skills by DS0000062638.V351702.R01.S.doc Version 5.2 Page 24 carrying out varied and specialist training. She generally works weekdays, including evenings. It is evident that residents benefit from a well run home. The manager confirmed that an annual service review is carried out regarding the service provided to residents by the care home. An up to date annual business plan was available for inspection. The manager confirmed that questionnaires about the service are supplied annually to residents, and to other stakeholders. The manager spoke of the positive action taken in response to this feedback. Records confirmed that records are kept up to date, and regularly reviewed. Those policies and procedures that were developed from the previous owner should show evidence of review and be updated in accordance to the systems in place of the present provider. Annual Quality Assurance Assessment (AQAA) documentation informed me that the manager was aware of action that could be taken to develop the format of policies/procedures particularly relevant and of interest to residents, so to improve their accessibility. Records confirmed that residents meetings take place. The home receives regular visits by a representative of the owner in which an audit of the service provided to people using the service is carried out. The home has a health and safety policy, and a manual handling policy. A monthly health and safety check is carried out. A health and safety poster was displayed as required. Certificates of worthiness in regard to servicing of electrical and gas safety systems in the care home were up to date. Fridge/freezer and hot water temperatures are monitored. Chemical cleaning products are stored securely. I was informed by the manager that a Legionella check of the water systems was carried out in 2006. The home has an accident/incident reporting policy. Incidents are recorded appropriately. The home has a fire risk assessment. This had recently been reviewed. It could include more comprehensive information regarding minimising some fire risks. This was discussed with the manager. Weekly fire checks take place. There have been two fire drills this year. These took place in the evening. Fire drills could take place more often and at different times of the day or night. A contractor serviced the fire systems during the inspection. A recent food safety inspection from an Environmental Health Officer, awarded the care home a four star rating. The employers liability insurance is displayed and up to date. DS0000062638.V351702.R01.S.doc Version 5.2 Page 25 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 4 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 3 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 DS0000062638.V351702.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 23(2) Requirement The carpet in the communal sitting room is stained in some areas and needs to be cleaned or replaced. Timescale for action 01/03/08 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 YA6 Good Practice Recommendations Staff should consider reviewing the care plan files and archiving non up to date information. • It should be more evident that residents are fully involved in their care plans, and that their care plans be more of a working document, and be more ‘person centred’. • Risk assessment should be further developed, and regularly reviewed to ensure that residents are supported to take risks as part of an independent lifestyle. • There should be a risk assessment in place in regard to staff working in the care home on ones own. Resident’s health action plans should be updated as and when their healthcare needs change, to ensure that staff DS0000062638.V351702.R01.S.doc Version 5.2 Page 27 • 2 YA9 3 YA19 4 5 6 YA20 YA24 YA32 7 8 YA37 YA39 9 YA42 and people using the service are aware of the changes. The medication procedure should record evidence of review and include information regarding Adepta rather than the previous owner. The curtain in one resident’s room should be fixed where it is hanging down. The registered manager should ensure that she regularly reviews staffing needs during the day to ensure that there are enough staff on duty to enable each resident to participate in 1-1 community activities, particularly in regard to some day resource sessions having been discontinued. The registered manager should ensure that she completes the NVQ level 4 Management course. • Policies and procedures that were developed from the previous owner should show evidence of review and be updated in accordance to the systems in place of the present provider. • Policies/procedures of particular relevance to residents should have the format reviewed to improve their accessibility to people using the service. • The fire risk assessment could include more comprehensive information regarding minimising some fire risks. • Fire drills could take place more often, and at different times of the day or night. DS0000062638.V351702.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: 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 DS0000062638.V351702.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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