Inspection on 10/08/07 for Apna House

This inspection was carried out on 10th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Apna House 23/06/06

Apna House 24/03/06

Apna House 06/10/05

Apna House 22/02/05

Apna House 26/11/04

Apna House 22/03/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Apna House 6 Park Avenue Hockley Birmingham West Midlands B18 5NE Lead Inspector Julie Preston Unannounced Inspection 10th August 2007 08:15a Apna House DS0000016857.V336529.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 Apna House DS0000016857.V336529.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. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Apna House Address 6 Park Avenue Hockley Birmingham West Midlands B18 5NE 0121 551 5678 0121 554 4322 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) Apna House Ltd Miss Hina Parmar Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13) of places Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years That the home provides personal care only for 13 people for reasons of mental disorder, excluding learning disability or dementia. The home can accommodate four named residents over the age of 65 years, whilst the home can meet their needs. The home must ensure that these named individuals needs are reviewed regularly, and a record made of this review. The home can accommodate one named individual who has a dual diagnosis. The home may accommodate one named service user over the age of 65 years, who is in a mentally stable condition. The Home may accommodate one named individual who has a primary diagnosis of Learning Disability. 23rd June 2006 4. 5. 6. Date of last inspection Brief Description of the Service: Apna House is sited in the Hockley area of Birmingham. It is well served by public transport affording access to the locality, Birmingham city centre and surrounding areas. The home is close to shopping facilities including specific cultural provision. Nearby are temples, mosques and churches attendant to all faiths represented at the home. Care is delivered in a large, refurbished double fronted house having tarmac frontage, ramped and stepped access to the main entrance and a small patio/garden at the rear mostly laid with tarmac and some small raised lawns. The home provides care, rehabilitation and recovery services to up to 13 adults who are experiencing problems with their mental health. It was reported that people whose first language is not English are able to converse with staff that will also advocate for them in their first language. The home currently accommodates male service users presenting a diverse range of mental health problems. Specific cultural needs are met through the provision of separate facilities for the storage and preparation of culturally appropriate food and adaptations to shower facilities for preparations prior to prayer. There are established links to other relevant professionals involved in mental health recovery services. Information is shared with people who live in the home at regular house meetings. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the inspection visit the manager sent to the CSCI their Annual Quality Assurance Assessment (AQAA). The completed assessment is the main way that a provider lets us know how well the service is delivering good outcomes for the people using it. The visit took place over one day and staff and people who live at the home did not know that we were coming. Three service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. The inspector had lunch with people who live in the home and talked to them about what it is like to live there. Some of their comments are included in this report. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. People who live in the home make decisions about their lives and receive good support from staff to do so. Some people said, “I have the freedom to do what I want here” and “I have responsibilities, which I like. It’s good here”. Care plans that explain how people need and like to be cared for are well written so that staff understand how to meet people’s needs. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 6 People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. Some information is provided to people in their first languages, making it easier for them to understand the content. There are opportunities for people to go out and do things they enjoy as part of a meaningful lifestyle. Staff have good understanding of peoples’ cultural needs and support individuals to take part in activities that are culturally appropriate. People who live at the home say they are confident they will be listened to if they have concerns or complaints and that staff will act to resolve any issues raised. What has improved since the last inspection? What they could do better: More training needs to be given to staff so that they understand how to support people with mental health problems. Some recommendations have been made to provide better outcomes to people with regard to health care planning, risk assessment (to help people stay safe), recording peoples’ belongings and medicines. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Apna House DS0000016857.V336529.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 Apna House DS0000016857.V336529.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): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: There is a statement of purpose and service user guide, which are made available to people who live in the home. The registered manager advised that both documents are being reviewed so that they provide accurate and accessible information about services and facilities to people who live or wish to consider living in the home. This will include formatting the documents in languages other than English and using photographs to illustrate services and facilities. The records of the person most recently admitted to the home were observed. There was evidence that an assessment of their needs had been made by staff at the home, Social Workers and family members to establish that the home Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 10 would meet the person’s needs. Trial visits had been recorded that showed the person had received several opportunities to stay at the home and “test it out” before deciding to move in. Apna House DS0000016857.V336529.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): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems of care planning and risk assessment in place to enable peoples’ needs to be understood and met. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: Three care plans were sampled. Each contained information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. The care plans had been reviewed within the last month to ensure they continue to be relevant to individuals’ needs. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 12 Risk assessments sampled had been reviewed on a regular basis and there was evidence that mental health care professionals had been involved in drawing up guidelines to enable staff to respond to peoples’ needs consistently. One risk assessment did not fully explain how the person should be safeguarded in a specific situation that could cause him harm or distress. The assessment instructed staff to “stop him”, which does not clearly describe how the person’s safety should be promoted. This should be reviewed so that the staff team have full and accurate information upon which to act to maintain the person’s safety within situations identified as being potentially hazardous. Staff spoken with demonstrated a clear understanding of the individual needs of the people living in the home and said that the guidance provided in care plans was sufficient to enable them to meet peoples’ specific needs. People who live in the home talked about some of the things they make decisions about as part of their day-to-day lives. Some people said that they had chosen new furniture and carpets for their bedrooms and made regular choices about meals and how they spend their leisure time. One person said, “I have the freedom to do what I want here” and another, “I have responsibilities, which I like. It’s good here”. Some people spoke about the value of having frequent “house meetings” to discuss the running of the home and plan group activities. There was evidence in the records sampled that peoples’ choices had been listened to and acted upon. For example, a barbeque had taken place, which had been suggested at one of the house meetings and people had had an opportunity to review the home’s menu and choose the colour and style of redecoration to communal areas within the building. Apna House DS0000016857.V336529.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): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported to take part in social and leisure activities they enjoy so that they experience a meaningful and culturally appropriate lifestyle. EVIDENCE: The activity plans and daily records of the three people whose care was being looked at were read and this showed that activities for people are varied, frequent and reflect their personal choices. Some people that live in the home have 1:1 support from staff to access community based resources and this had been well planned by the management team to ensure that people receive the support they need to maintain a meaningful lifestyle. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 14 People talked about the things they enjoy doing and this included going out to the local Mosque, cooking, shopping, visits to the library and cinema, arts and crafts and eating out. Staff at the home provide good support to enable peoples’ cultural needs to be met. At this visit people were assisted to wash for Friday prayers at the Mosque and choose traditional clothing for the occasion. The home has Sky television, which includes Zee TV, an Asian network channel, that many people said they enjoy watching. There was evidence that some people had drawn up their own activity plans where they were able to do so. One person said, “I have a weekly plan but if I choose something else, that’s fine. It’s not strict, I please myself”. Staff have made effort to present information about activities to people in picture format, where this is appropriate to individuals’ communication needs. People who live in the home said that they have a lot of contact with their friends and relatives, receiving visits at Apna House and inviting them to special events such as parties and religious celebrations. One person said he was very happy that staff had supported him to attend two family weddings recently. Food stocks were looked and supplies were found to be ample, with plenty of fresh fruit and vegetables. The records of menus showed that a range of food is offered providing a well balanced diet. At lunchtime people chose what they wanted to eat from a range of eight dishes including salad, watermelon, dhal, sandwiches, sabjee, lamb and rice. Records of food eaten are kept so that it can be evidenced that people receive a healthy and balanced diet, in accordance with their needs and preferences. There are opportunities for people to shop for and cook their own food, where this is part of their plan of care. The home has a small kitchen, separate to the main one, which can be used for preparing and cooking food. This was being used during the visit by people making hot drinks and snacks. One person said, “I like being able to cook my own food, but if I don’t feel like it I eat what the cooks have made.” Apna House DS0000016857.V336529.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): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and personal care plans are well written so that people’s needs are consistently met to ensure their ongoing health and well being. People who live in the home receive their medication safely and as prescribed by the GP. EVIDENCE: Care plans described how people like to receive their personal care and their preferred routines, such as having a bath instead of a shower. Staff were observed interacting with people who live in the home and offering support in a friendly and respectful manner. All staff were aware of the need to provide personal care in private so that people’s dignity was not compromised. People living in the home had clearly been supported with personal care and grooming at this visit. Staff had planned time to assist people to wash and dress for Friday prayers at the Mosque. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 16 It was pleasing to note that within the care plans sampled emphasis had been placed on the person’s strengths as well as their needs so that people retain their independent living skills. For example, a plan described the person being able to choose their own clothing but needing help to get changed if the clothing became soiled. This person confirmed that he did choose his own clothes each day. There was sufficient evidence within the care plans sampled that staff at the home have consulted health care professionals for support and guidance to meet individuals’ needs with regard to promoting their mental and physical health. Records were seen which showed that mental health and medication reviews had taken place on a planned basis for people living in the home to enable them to continue to enjoy good health. Appointments with health care professionals are recorded and include the outcome of each visit so that staff have accurate and up to date information about peoples’ needs and how care should be provided. In one instance it was noted that a person had refused dental treatment on a number of occasions, however this issue had not been fully incorporated into his plan of care. It is recommended that this care plan be reviewed so that there is strategy for the person to access health care services that meet his needs. The home provides satisfactory secure storage for peoples’ medicines. Medication is received into the home using the monitored dosage system in blister packs. The Medication Administration records (MAR) cross-referenced with the blister packs sampled indicating that medication had been given as prescribed. Some PRN (as required medicines) are prescribed. There was evidence of written protocols to describe the circumstances under which the medicines should be given so that people receive the medication in a consistent way. The MAR for one person’s PRN Lorazepam showed that the medicine had been given out on four occasions within the period sampled. The MAR had been signed by staff, however there was no description on the reverse of the record to indicate the reason for administration. It is recommended that this be included in the home’s medicines procedure as part of good practice for managing medicines. Staff who administer medication have received training, which should ensure that people receive their medication safely. This is an improvement from the last inspection. Apna House DS0000016857.V336529.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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: The home has a complaints policy and procedure that is made available in a variety of languages including English, Hindi and Gujarati, which is reflective of the needs of the people living there. The complaints log was looked at which showed that concerns and complaints are listened to and acted upon quickly. The home has not received any complaints within the last twelve months. Questionnaires issued to people living in the home as part of a review of the quality of service provided indicated that people know they have the right to complain and understand how to raise concerns and complaints. This was confirmed during the visit by some people who said, “I tell the staff if I’m not happy” and “I’d always tell Hina (the manager) but I’ve never needed to”. Other responses from the questionnaires sampled stated that people feel safe and happy within the home. There are policies and procedures in place with regard to protecting people from abuse and potential harm. Staff have had training in adult protection and Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 18 managing challenging behaviour as part of the home’s safeguarding policy. Two people who live in the home took part in recent challenging behaviour training with the staff team. One of the people said, “This was good as I gave my views about why I could be aggressive. It might help the staff understand more”. Since the last visit to the home, an incident has been dealt with under adult protection procedures. This was appropriately reported to the CSCI and investigations were led by officers from the appropriate social work team, in keeping with the home’s adult protection policy. There was no evidence to support any misconduct by staff in the home and it was clear from the records sampled that the staff team takes the safeguarding of vulnerable adults seriously. There was further evidence that care plans and risk assessments had been reviewed following the incident, for the ongoing protection of people who live in the home. A number of other safeguarding measures were seen to be in place including monitoring records for people who demonstrate behaviour that is challenging. There was evidence that the records had been used at the person’s mental health reviews to determine any patterns or triggers to the behaviour and subsequently devise guidance to promote the person’s safety and well being. Inventories had been completed describing the property of people who had recently moved to the home so that staff could track if anything had gone missing and to make sure that people’s belongings are looked after. It is recommended that inventories be kept for each person to ensure that their belongings are accounted for. Apna House DS0000016857.V336529.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): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well furnished, warm, clean and well decorated which provides a comfortable and safe environment for the people who live there. EVIDENCE: Apna House is located off the Soho Road near to Birmingham City Centre. There are public transport routes nearby, which is important to the people who live in the home as they use buses to access their local community. Places of worship including the Mosque and Gurdwara are also conveniently situated and well used by the people who live at Apna House. The home is a large double fronted building with ramped access to the front door and has off road parking space for visitors’ cars. A tour of the premises was undertaken at this visit and several major improvements were noted. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 20 All bedrooms and communal areas had been redecorated and recarpeted. People said that they had chosen the colour schemes for their bedrooms and the dining room. New windows had been fitted throughout, which creates a more pleasant environment for people to live in. There is a large dining room that had been refurbished and redecorated, which people said they really liked and offered “a nice place to eat”. Some work had been done in the rear garden to make it a more attractive place for people to use. New turf had been laid and garden furniture purchased, which people said they appreciated. The building was clean and hygienic throughout. There are established policies and procedures in place for the control of the risk of infection and staff practice during this visit were seen to adequately protect the well being of the people living in the home. The majority of staff have completed training in infection control, which should ensure safe standards of hygiene are maintained within the home. There was evidence in written records and from comments received from people who live and work at Apna House that repairs and maintenance work are responded to promptly, which is an improvement from the last inspection. Apna House DS0000016857.V336529.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): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from the support of a staff team who have had recent opportunities to develop their skills and knowledge, however some training has not been provided which could lead to individual needs not being met. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: Staff were observed interacting with people who live in the home in a friendly and respectful way. It was evident from discussion with staff on duty that they have established good relationships with people and understand their needs. People commented that the staff team are “very, very good” and “listen very well”. One person said that the home was the best he had ever lived in and found all staff friendly and kind. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 22 Documentation received before this visit indicated that all staff have either completed or enrolled to begin training at NVQ Level II or above. This is considered positive as the figure is in excess of the 50 specified within the National Minimum Standards. Of the thirteen staff employed, just under half of the team are male, which is reflective of the gender of the people currently living in the home. The staff team reflect the cultural backgrounds of people who live in the home and from observation of their practice it was clear that they demonstrate effective knowledge of individuals’ cultural needs. The recruitment records of two recently employed members of staff were sampled which showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. Staff training records sampled showed that improvements to the frequency of training had taken place since the last inspection. Mandatory health and safety training had been provided to assist the staff team to meet people’s needs. Some specific training such as managing challenging behaviour had been made available, which is reflective of the needs of the people who live in the home. There was no evidence to indicate that training in mental health awareness or the Mental Capacity Act (MCA) 2005 and the MCA Code of Conduct had been offered to staff or planned for the future. This must be addressed so that the team have the necessary skills and knowledge to fully support people living in the home. Apna House DS0000016857.V336529.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): 37, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a home that is well run. General practice promotes the health, safety and well being of people who live there. EVIDENCE: The home has a registered manager who has been in post for six years and has completed her Registered Manager Award and is awaiting verification of her NVQ Level IV in care. The registered manager is supported by a Deputy and Senior member of staff, who take responsibility for designated managerial tasks. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 24 During this visit, a good relationship was observed between the management team, people who live in the home and the staff team and the atmosphere was both welcoming and relaxed. Quality assurance systems are in place. House meetings occur every 4-8 weeks and people are encouraged to give their views about the way the home is run. Records showed that people had discussed a range of topics such as menu and activity planning and health and safety around the home. A representative of the registered provider visits Apna House on a regular basis to comment on the standard of care provided, which contributes to the effective management of the home for the benefit of the people who live there. Surveys issued by the home to visitors indicated that the home is well managed. A response from a Social Worker stated, “There is excellent quality of care”. Family members commented, “It is very friendly and efficient” and “The best home we have come across”. At this inspection the home received a visit from a representative of West Midlands Fire Service (WMFS), to check the fire safety procedures in place. The WMFS officer observed the home’s written fire risk assessment and commented that it was satisfactory, stating that there were no concerns about established fire procedures. One recommendation was made, that a written disaster plan is necessary should the home be assessed as unsafe in the event of a fire. The registered manager agreed that she would follow this matter up. Fire safety records showed that equipment had been tested and serviced on a regular basis to make sure that it was working for the ongoing protection of people who live in the home. There were certificates to show that gas and electrical equipment had been serviced to make sure they were fully functioning and safe for use. Records of fire drills evidenced that people have regular opportunities to practice evacuating the building in the event of an emergency. Staff had received training in fire safety awareness so that they know what to do in the event of a fire. There was evidence to show that the water system had been treated for the prevention of Legionella and is tested on a regular basis. The home received a visit from Environmental Health Services in May 2007. Some recommendations were made to promote safer health and safety practice, which were promptly addressed by the staff team and found to be satisfactory when a second visit took place in July 2007. Apna House DS0000016857.V336529.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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 3 X X 3 X Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 YA35 Regulation 18(1)(c)(i) Requirement Staff must receive suitable training in mental health care awareness and mental capacity so that the needs of people living in the home are understood and met. Timescale for action 30/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA9 YA19 YA20 YA23 Good Practice Recommendations Risk assessments should fully explain how staff should act to safeguard people who live in the home for their ongoing support and protection. Dental care plans should be reviewed for people who refuse treatment so that there are strategies in place to ensure people receive the care they need. Medication Administration Records should be completed with details of the reasons for PRN (as required) medicines being administered. Inventories of peoples’ property should be maintained so that individuals’ belongings are accounted for. Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Apna House DS0000016857.V336529.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!