Inspection on 20/09/05 for Apna Ghar

This inspection was carried out on 20th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Apna Ghar 26/02/07

Apna Ghar 15/03/06

Apna Ghar 29/03/05

Apna Ghar 03/06/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Apna Ghar 1 Kingswood Road Gillingham Kent ME8 9RS Lead Inspector Anne Butts Announced 20 September 2005 10:00 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 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 Stationary 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. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Apna Ghar Address 1 Kingswood Road Gillingham Kent ME17 1EA 01634 850445 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Nilofer Englefield Care Home Category(ies) of Mental Disorder (2) registration, with number Mental Disorder -over 65 (1) of places Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: One(1) person over 65 with mental health difficulities. Two(2) people with mental health difficulties. Date of last inspection 29 March 05 Brief Description of the Service: Apna Ghar is a small privately run home situated a few minutes walk from the centre of Gillingham and the train station. It has easy access for all local amenities. The home occupies a semi detached premises on a corner plot with homely accommodation situated over two floors. It offers 24 hour care for people with mental health difficulties of ethnic minority and this is reflected in the care and support provided by the management and small stable staff team. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on 20th September 2005. It was carried out by, Anne Butts, who was supported by Sue McGrath – this was to ensure that there was a continuity for the home with regards to the inspection process. Both inspectors were impressed by the commitment shown management of the home in supporting the service users and staff. by the Time was spent viewing documents, talking to service users and touring the environment. What the service does well: What has improved since the last inspection? What they could do better: Overall the records reflect how to meet individual needs, although in order to better protect service users personal safety a wider range of risk assessments need to be implemented. The storage of medication could be improved by ensuring that a more secure cupboard is in place. The kitchen unit and drawer surrounding the sink area would benefit from being made good and some tiles in the bathroom are in need of repair. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 6 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. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 standard(s) 1, 2 3 and 4 Current and prospective service users can be confident that the home ensures that they have enough information to be able to make an informed decision about where to live. Prospective service users benefit from an assessment process that ensures needs can be fully met. EVIDENCE: The Statement of Purpose and Service Users Guide currently hold all the required information and were evidenced in service users files, they were signed and agreed by all service users who are currently in the home. These were not evidenced as being in a format that was suitable for the service users needs but throughout the inspection process it was shown to the inspectors that management and staff work through all the paperwork processes with the service users and ensure that they have a full understanding. In particular the General Social Care Council code of conduct booklet had been produced in formats that include picture format and different languages and both inspectors were confident that all current service users had been given enough information. In the files viewed there was evidence of very comprehensive needs assessment to ensure that individual needs are met or can be met for new service users within the home. The initial needs assessments is supported and integrated with an assessment from the care management team and this is Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 9 then incorporated into the plan of care that is used to support the service users within the home. The manager stated that all prospective service users are assessed prior to moving into the home, and that they have the opportunity to look around the home and spend some time with the current service users and that they are able to have a chance to ensure that this could be a home that they could live in. The manager also confirmed that current service users are also introduced and consulted about any prospective service users who may be moving into the home. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 , 9 and 10. Service users are able to participate in their care plans and know that their needs will be met. They would be better protected by a more in depth range of risk assessments. EVIDENCE: Service users’ records were viewed and they evidenced that service users participate in the care planning process, and that regular reviews take place in order to meet any changing needs. The home obtains a care plan from the referring professional and this is then used as a basis to develop the homes care plan for the service users. Care plans are fairly basic but they contain enough information for staff to be able to support service users in meeting their needs. A service user spoken to described how she is able to participate in the general day to day running of the home and is actively involved in the organisation of the meals and shopping. There were some risk assessments in place but these did not fully encompass many aspects of the individual service users lives. It was recommended that Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 11 as reviews take place the manager should take into consideration any risks and identify how to support service users in reducing hazards. Records are kept securely and locked away and the home has a confidentiality policy in place. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 and 17. Service users benefit from being actively involved in the daily running of the home and can be confident that they are able to make positive choices about their lives. Service users are well supported in meeting their religious and cultural needs and benefit from being involved in the meals and menu planning. EVIDENCE: Care plans and personal files for the service users showed how they are supported with their daily living. They identified their preferred daily living choices and any routines they had established. They are able to come and go as they please and religious needs are met and promoted. One service user spoken to described how she goes out and meets friends and also stays with family. Records showed that consideration is taken and individuals are consulted about their hobbies and personal preferences. There is no structured activities programme within the home, but it was evident that service users are able to pursue their own interests. The manager Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 13 also described how they are looking into planning a holiday to India, where the service users will be able to visit any family. The home supports service users with managing their personal finances and any monies are fully recorded and kept securely for the individual. Service users have their own keys if they wish, although one service user prefers not to as she “keeps losing it”. The service users are mainly vegetarian and this is taken into account with the meals and menu planning. It was also evident that service users were encouraged to take part in the cooking and preparation and this was in keeping with cultural and religious requirements. Food intake for service users was monitored and records of food eaten kept in order to promote and monitor nutritional needs. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20 and 21 Personal needs are provided in a sensitive manner that supports service users’ preferences. Health needs are met and service users benefit from having full access to all professional health care services as required. EVIDENCE: Care plans included how service users are supported with their personal needs by staff and evidenced that their choices and preferences are taken into account. Records also showed that service users are able to access G.P.’s, dental appointments and the optician. All service users are supported by appropriate health care professionals in meeting their needs and regular reviews take place and these are fully documented and taken into account in supporting service users. The staff support the service users with their medication management and full records are kept. Medication is kept in a cupboard but it was recommended that the manager looks into making more secure arrangements for the storage of medication. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 15 All service users had been consulted with about their preferences with regards to the issues surrounding aging, illness and death and records evidenced that this had been carried out in a sensitive manner. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 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 standard(s) 22 and 23 Service users can be confident that their complaints will be dealt with effectively through the home’s clear complaints system. Robust adult protection policies and procedures and staff who are trained protect service users. EVIDENCE: There have been no complaints registered since the last inspection. The manager stated that if any concerns are brought to her attention they are addressed at the time. Records showed that issues that cause concern to individuals are recorded and dealt with in appropriate manner. There is a full complaints procedure in place. A service user confirmed that if she wanted to make a complaint she knows who to go and that “I feel safe and secure living here – they are nice people who look after me”. All staff have completed Adult Protection training and the home has policies and procedures in place and have adopted the Kent & Medway Adult Protection Protocols in order to ensure that both service users and staff are fully protected. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. Service users can be confident they will live in a clean and homely environment that promotes their independence. EVIDENCE: A full tour of the home was undertaken and it was clean and homely. A redecoration programme has been implemented since the last inspection and all service users bedrooms have been redecorated alongside some communal areas with new furniture being put into place. In appropriate places some nonslip flooring has been fitted – but this does not detract from the overall homely environment. One service user who was in the home on the day of inspection stated ‘Have you seen my room? - It is nice and my bed is really comfortable’ There is a bathroom and toilet on the first floor, which appears to meet all service users needs and was clean – there are some fitted tiles around the bath that are cracked and broken and need to be made good, and a recommendation has been made to this effect. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 18 All service users within home are ambulant and there is no need at the current time for any specialist equipment. There is a separate utility room that has a washing machine and dishwasher. It was evident on the day of inspection that service users have full access and are able to carry out their own chores if they so wish. There was appropriate hand washing facilities in place. The kitchen area was clean and well maintained, although the unit doors around the sink area and some drawers will be in need of some maintenance in the near future and this was mentioned at time of inspection. Water temperatures are regulated through the main system and the inspectors recommended that this is still checked on a regular basis to ensure that service users are not at risk of being scalded and this should then be recorded in an appropriate manner and a system to implement this was put into place immediately. Overall Apna Ghar is a home to the people who are living there and this was evidenced throughout the inspection process by the comfortable and congenial atmosphere into which the inspectors were welcomed. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36 Service users are protected and supported by staff who are competent and qualified in meeting their needs. EVIDENCE: The home caters for a small group of service users with specific needs and their training and supervision programme reflects this. All staff have completed mandatory training requirements plus some additional training which assists in meeting the needs of this service user group. All staff within the home have either completed at least an NVQ level 2 or above in care – or are close to completion. This exceeds the guidelines set and the management and home can only be recommended on this. Certificates were viewed which confirmed all training undertaken by staff. The inspectors were very impressed with the training and support provided to staff and the only comment that can be made is to ensure that any ongoing training needs are kept up to date. There have been no new staff members employed recently but the manager was able to talk the inspectors through the recruitment process. The induction procedure was viewed for the last member of staff who was employed and this Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 20 was comprehensive and covered all areas of the care and support for the service users. Records evidenced that staff meetings are held on a regular basis and one to one supervisions are also in place. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40 and 41. Service users benefit from living in a home where the manager is competent and experienced with a clear vision for the home. Service users are protected by the homes policies and procedures and record keeping processes. EVIDENCE: The manager has completed NVQ level 4 for both Care and the Registered managers’ award and also keeps herself up to date with any other training requirements. She maintains the documentation within the home to a good standard. Records showed that regular meetings are held with service users and that they all participate in the running of the home. This was substantiated by a service user who stated; “I am very happy here – I like doing the cooking and helping out with the menus.” Service users are also actively involved in the reviewing of their care plans. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 22 The home has a development plan, which includes a maintenance programme. There is also a comprehensive quality assurance programme in place which includes gaining views from service users, families and professionals. There is a full list of policies and procedures in place and these are working documents that reflect the ongoing and changing needs of the service users in the home. They are accessible to all staff and service users and the manager explained that staff will sit with service users and go through documentation as needed. Throughout the inspection process – records viewed and the manager all evidenced that the home is committed to meeting all needs. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 23 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 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Apna Ghar Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 x x H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 24 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 Regulation Requirement Timescale for action 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. 2. 3. 4. Refer to Standard Y.A. 9 Y.A. 20 Y.A. 24 Y.A. 24 Good Practice Recommendations it is strongly recommended that risk assessments are expanded to include all aspects of service users daily lives in order to better protect their personal safety. It is recommended that medicine storage is reviewed and improved. it is recommended that the kitchen unit and drawers surrounding the sink area are made good. It is recommended that any cracked or broken tiles in the bathroom are made good. Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Apna Ghar H56-H06 S28849 Apna Ghar V242274 200905 Stage 4.doc Version 1.40 Page 26 - 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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