Inspection on 10/06/08 for Bedford Road 7

This inspection was carried out on 10th June 2008.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bedford Road 7 11/11/08

Bedford Road 7 16/07/07

Bedford Road 7 19/05/06

Bedford Road 7 12/01/06

Bedford Road 7 29/11/05

Bedford Road 7 13/09/04

Bedford Road 7 26/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Bedford Road 7 Flat 1, 31 Haringey Park London N8 9JD Lead Inspector Susan Shamash Unannounced Inspection 10th June 2008 13:45 Bedford Road 7 DS0000010716.V365538.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 Bedford Road 7 DS0000010716.V365538.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. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bedford Road 7 Address Flat 1, 31 Haringey Park London N8 9JD Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8800 2864 020 8800 2864 bedfordrhailltd@btinternet.com HAIL (Haringey Association for Independent Living Limited) Samuel Conteh Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD 2. Physical Disability - Code PD The maximum number of service users who can be accommodated is: 6 16th July 2007 Date of last inspection Brief Description of the Service: Bedford Road is a home registered to provide residential care to six people who may have learning disability or physical disability. The building is provided by Circle 33 Housing Association and the services are provided by Haringey Association for Independent Living (HAIL). The home is located in a residential area close to the Seven Sisters Underground and shopping facilities. There are six single bedrooms, three bathrooms/showers and three toilets. There is a lounge, a kitchen, a dining room and a large garden at the rear of the building. The ground floor of the home is wheelchair accessible even though the current people living at the home do not require this. The home has stated objectives of enabling people to live as independently as possible, with the same range of choices as any other citizen, mixing as equals with others and being members of their own community. Information about the home is including in the home’s brochure and the CSCI inspection reports are available from the home by contacting the provider or from the CSCI website - www.csci.org.uk. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 5 The weekly fees of the home depend on people’s assessed needs, but the average weekly fee is £1053.44 as of July 2008. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as a routine key standards inspection of the home and lasted approximately six hours from 1.45pm to 7.45pm on a Tuesday evening. I was assisted by the deputy manager and other staff working at the home. At the time of the inspection, the registered manager had been suspended from working at the home for approximately two months, with alternative management arrangements in place. All but one of the people who live at the home were out during the day, when I commenced the visit, but returned to the home later during the inspection. I had the opportunity to talk with and spend time with all people living at the home and spoke to three staff members independently. The inspection also included a tour of the building, assessment of three people’s care files, three staff files and six training files, health and safety records, rotas and menus and medication administration records. What the service does well: New people’s needs are assessed in detail before their admission to ensure that they can be met by the home. Comprehensive care plans and risk assessments are in place and these are reviewed regularly to ensure that people’s needs are met. A key working system is in place at the home, and monthly summaries of care needs and activities are recorded, to ensure that responsive care and support is provided. People live in a generally well maintained and pleasant environment and can access all communal areas. Their health needs are closely monitored and arrangements are made for them to see appropriate health professionals. The complaints procedures and the policies in relation to the protection of vulnerable adults from abuse are appropriate. The food provided is of good quality and meets the nutritional needs and preferences of people living at the home. The home is active in supporting people to access a variety of leisure, educational and other day activities according to their choices. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 7 An annual holiday away from the home, is arranged for residents, with staff support to ensure that they can be involved in activities of their choice. What has improved since the last inspection? What they could do better: All staff must receive current training in food hygiene and first aid, to ensure that people living at the home are protected from harm, and monthly unannounced visits must be undertaken on behalf of the provider organisation to monitor the quality of care and support provided by the home. These requirements are not restated in this report, however the CSCI is considering taking enforcement action to ensure compliance in these areas. It remains required that all restrictions placed on people living at the home must be clearly outlined in their care plans, with the signed agreement of all relevant parties to ensure that their rights are respected. Clearer records must be maintained of meals served to individual people living at the home, to evidence that their cultural and nutritional needs are met. More rigorous recording of people’s weights is needed, to ensure that the health needs of people living at the home are addressed appropriately. Recording of medicines brought into the home is needed to ensure that people’s medication needs are met safely. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 8 Some improvements to the home environment remains outstanding and action must be taken to ensure no further disruptions to the supply of hot water in the bathrooms for people living at the home. Sufficient staff must be working in the home at all times and they must have regular supervision, to ensure that they work in line with best practice and can support people with activities outside of the home and address unforeseen emergencies without risk. The current Annual Quality Assurance Assessment must be completed for the home and a quality assurance audit must be undertaken for the home, to ensure that the home is run in the best interests of people living at the home. Weekly fire alarm tests must be carried out without gaps, and a current satisfactory electrical installation certificate must be available for the protection of people living and working at the home. It is of concern that several requirements have been restated in this report. Any unmet requirements impact upon the welfare and safety of people living at the home. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 9 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 Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 10 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): 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. New residents can be confident that their needs are assessed by the home prior to their admission to ensure that they can be met. EVIDENCE: No new people had been admitted to the home since the previous inspection. All residents’ files that were inspected included detailed assessments of their needs by the home as well as assessment information from their social worker and health professionals. The assessments carried out by the staff included details of the physical, emotional, personal care, cultural, dietary and social needs of each person. The staff had also made observations of their opinions of prospective residents’ compatibility with the existing people who live at the home. Staff confirmed that they were provided with sufficient assessment information about all the people living at the home. Bedford Road 7 DS0000010716.V365538.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 and 9. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home can be confident that their needs will be addressed appropriately and responsively. They are supported to make decisions about their lives and to take informed risks to maximise their independence, but their rights are not sufficiently protected by recording of agreements to restrictions placed on them. EVIDENCE: Three people’s care files were inspected in detail and two further care files were examined briefly. It was evident that care plans and risk assessments had been reviewed at least six-monthly and that there had been some consultation with families and representatives regarding support provided. The home operates a key working system and discussions with the staff and an examination of the files indicated that each key worker writes a monthly summary of significant events and activities for people living at the home. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 12 Detailed care plans and risk assessments were in place for the three people whose files I inspected. These took account of cultural needs and lifestyle choices indicating how these needs were being met. However, despite this being required at the previous inspection, restrictions placed on service users were still not being clearly outlined in people’s care plans alongside the signed agreement of all relevant parties. For example, for safety reasons one person’s belongings are stored outside of their room, however the care plan does not make this clear, nor is their evidence of consultation with advocates of behalf of this person. As required the care plan and risk assessments regarding eating/feeding arrangements for one person, had been updated to ensure that their care needs are met appropriately. Discussion with staff members made it clear that the home encourages people to realise their potential by adopting suitable methods of supporting each individual. Risk assessments, observations and discussion with staff and residents indicated that people are supported to take some risks as part of developing their independent living skills. Observations of staff interacting with people living at the home confirmed that they treated people with respect, maintaining their privacy, dignity and respecting their cultural and lifestyle choices whilst supporting them with personal, social and emotional care. Bedford Road 7 DS0000010716.V365538.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, 14, 15, 16 and 17. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are generally satisfied with the range of activities organised and facilitated by the home including educational and recreational activities both inside the home and within the local community. However some cancelled activities due to insufficient staffing numbers has impacted negatively on people living at the home. People are supported to maintain contacts with friends and family and also enjoy an annual holiday away from the home with support from the staff team. The food provided at the home is of good quality and appears to meet people’s dietary needs and preferences. EVIDENCE: All the people who live at the home attend day services on the majority of weekdays. From their personal files and documents it was evident that the Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 14 home liaises with day centres, and that staff support people to attend other activities within the local community. Staff advised that people at the home continue to be involved in a wide range of activities during the day. Observation and interactions with people living at the home indicated that they were generally supported to be involved in activities of their choices both inside and outside of the home and this was confirmed in daily notes recorded. Residents had been on a holiday to Suffolk last year and photographs were available from this and other leisure activities undertaken. Other activities recorded in residents’ files included regular massages, bowling, playing football in the park, trips to the coast, Epping Forest, Finsbury Park, Broadwater farm and Victoria park, pub and restaurant meals, picnics and shopping trips. One resident told me that they were planning a holiday in Spain, and staff confirmed that this was being looked into. This person had stayed at home that day to be supported by staff in activities within the local community, as part of their activities programme for the week. However due to staff shortages this person was unable to go out during the day and towards the end of the afternoon they had become visibly agitated. They were also unable to go out in the evening due to a medical emergency regarding another resident. When I looked at this person’s daily records, I was concerned to see that on several of the days that they were due to be supported in the local community, they had in fact stayed at home. Three staff members that I spoke to, attributed this largely due to insufficient staff. They also advised that it is far more difficult to carry out evening activities, either inside or outside of the home, due to frequent shifts with only two instead of three staff on duty. The deputy manager advised that she is currently taking action to address this issue. A requirement is made accordingly. Discussions with members of the staff team and an examination of care plans indicated that no people living at the home currently choose to attend a place of worship, although this option is available to them. It was also evident from people’s files and discussions with the staff that people living at the home enjoy visits by and to family and friends. My observations of people living at the home showed that they were very relaxed and comfortable within the home accessing communal areas as they wished. I was impressed to see staff encouraging residents to be as independent as possible, e.g. one person washed up their own plate following the evening meal, even though this took an extended period of time. Staff showed great patience and awareness of people’s abilities and preferences throughout the shift. All people living at the home require support with financial management. There are appropriate systems in place to safeguard people’s money being looked after by the home, and at the end of each shift staff check the money and Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 15 records and handover to the staff on the next shift. Receipts are kept for all transactions with people’s monies and the home’s petty cash. The home has a four weekly rotating menu. The menu is displayed in the dining room. The staff spoken to explained how they support people to choose meals with the use of pictorial symbols. I noted that people appeared to enjoy the evening meal served at the home, and that the mealtime atmosphere was pleasant and unrushed. The home was well stocked with food including fresh fruit and vegetables, and people living at the home indicated that they enjoyed the food provided. However although staff explained people’s preferences to me, including cultural alternatives such as curries and West Indian foods, there was no clear record of which meals were eaten by which residents. This is required to evidence that people’s cultural and nutritional needs are met. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 16 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 and 20. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal and health care needs are met by experienced staff and clear procedures to ensure that they receive regular support from healthcare professionals. There remains room for improvement in the recording of medication administration and people’s weights, to ensure that people living at the home are protected from harm as far as possible. EVIDENCE: I observed all residents being treated with respect by staff members, and it was clear that trusting relationships had been formed between staff and residents. There was a good deal of interaction between residents and staff members during the evening of my visit, I witnessed staff supporting people with musical activities and puzzles, whilst ensuring that their physical needs were met appropriately. The home has a procedure for regularly updating people’s assessments and care plans and works closely with health professionals and day centre officers. It was clear from discussion with staff and an assessment of the home’s diary and people’s files that that people living at the home are supported to see their general practitioners, dentists, opticians and chiropodists on a regular basis. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 17 However I was concerned to note that there were irregular time periods between the weight records in three people’s care files, and in one case where there appeared to have been a loss of 3.5kg within two months, there was no evidence of action taken, and they did not appear to have been weighed again since January 2008. A requirement is made accordingly. The home monitors and records the temperature of the area where medicines are kept on a daily basis to ensure that this remains below 25˚C as appropriate. As required at the previous inspection, clearer directions were recorded for administering medication rather than ‘as directed’. Medication administration records were complete with no gaps indicating that people had been receiving their medicines appropriately, and I observed medicines being administered to one resident, in an appropriate manner. However there were no records of medicines received at the home during the last month. There is also a need for discontinued medicines to be removed from medication administration records. One staff member told me that they had asked the pharmacist to remove discontinued medicines from the records on a number of occasions but this was still not being addressed. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 18 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 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. The home has satisfactory policies and procedures to ensure that people are protected from abuse and that their concerns and complaints are listened to and dealt with. EVIDENCE: The complaints procedure is written with pictorial illustrations for use by nonverbal people living at the home. A copy of the procedure is included in the home’s brochure and the statement of purpose. There had been no recorded complaints since the last inspection. Copies of staff training certificates in the Protection of Vulnerable Adults were available in the staff files inspected. Staff spoken to confirmed that they had undertaken this training and were aware of action to be taken in the event of a disclosure or suspicion of abuse. They confirmed that they have read the home’s policies including the whistle blowing policy, and were aware of things to look out for in the behaviour of non-verbal residents that might indicate cause for concern. There is also a copy of the placing authority’s adult protection policy and procedure within the home. Bedford Road 7 DS0000010716.V365538.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 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People generally live in a comfortably furnished and decorated environment. However there is room for a small number of repairs and improvements to further improve their standard of living. The home is generally clean and hygienic, however infection control procedures do not ensure that people living and working at the home are protected as far as possible. EVIDENCE: A number of repairs had been undertaken in several residents’ rooms as required at the previous inspection. As required that carpet on the first floor hallway had been thoroughly cleaned, but the deputy manager advised that the carpet was due to be replaced. The new oven and cooker purchased for the home had now been fitted, thus improving the kitchen facilities. A new armchair had not yet been provided in an identified person’s bedroom on the ground floor of the home, but staff assured me that this item of furniture had been ordered and was due to be delivered shortly. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 20 Discussion with the housing association, who own the property, indicated that the replacement of the flooring in the ground floor wet room, and the first floor shower would not be undertaken until 2009. Action had been taken to address a large crack in the flooring in the lounge which had apparently involved considerable work. Although evidence was available that the extractor fan in the ground floor toilet had been repaired following the previous inspection, it was out of order again at the time of the current visit, and a maintenance report had been recorded as appropriate. As required at the previous inspection, hand-drying facilities had been installed in the toilet rooms. Hand-towel dispensers had been fitted and these were stocked with hand towels on the day of the current inspection. At the previous random inspection it was required that an infection control audit be undertaken for the home. Although a risk assessment was available, this only considered food hygiene procedures and did not make reference to laundry facilities or toilet facilities, and therefore requires further work. The premises were clean and bright and there were no offensive odours. There are handrails in the corridors, adaptations in bathrooms, toilets, and shower rooms and the radiators are guarded. I was concerned to learn from maintenance records that there had been repeated incidents in the last month, during which some bathrooms had no hot water. Staff members confirmed that this had been a problem and was still being addressed with the housing association. This must be addressed without delay. Bedford Road 7 DS0000010716.V365538.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, 34, 35 and 36. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected from abuse by rigorous recruitment procedures for the home. They can be sure that the staff team are suitably experienced to meet their needs appropriately. However insufficient staffing numbers, training and supervision may mean that their needs are not met safely. EVIDENCE: I spoke to three staff members during the visit, and observed staff interacting sensitively with people living at the home. Discussion with them indicated that they are very aware of people’s needs but there were clear concerns about times when insufficient staff are on shift to be able to provide residents with the stimulation that they need. On the day of the inspection one person was unable to go out in the community due to insufficient staffing and records indicated that this had happened several times previously. Later during the visit, one resident returned early from the day centre due to concerns about them having an injury to one hand. Due to a staff member cancelling a shift at the last moment, the deputy manager struggled to find cover so that this person could be taken to hospital for a check up. This was Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 22 arranged, and the person was supported to go to the local accident and emergency department. However although this person is risk assessed as needing two people supporting them when out in the community, only one person was able to accompany them on this occasion. Sufficient staff must be available in the home at all times, to ensure that people can undertake activities outside of the home, and that emergencies can be addressed safely. Three staff recruitment files were inspected, alongside the training undertaken by a further three staff members. All staff members had satisfactory Criminal Records Bureau (CRB) checks from the current employer. The home had also obtained two written references for each member of staff. There was also evidence of identity documents checked and some induction training. Files for the bank (as and when) staff are kept at the head office and therefore it was not possible to check if they have all necessary items in their files. Training files for six staff members were inspected indicating that a wide range of training had been undertaken including relevant Learning Disabilities training, protection of vulnerable adults, medication, health and safety, manual handling, risk assessment and communication awareness. A large proportion of staff had undertaken or were undertaking relevant NVQ qualifications. At the previous inspection it was required that all staff undertake updates in food hygiene, first aid and fire safety to ensure that these qualifications are current for the safety of people living at the home. Records showed that fire safety training had been undertaken as appropriate and this was confirmed by staff. However records showed that only one of the six staff members had up to date food hygiene training and only two had current first aid training. This requirement is not restated in this report, however the CSCI is considering taking enforcement action to ensure compliance in this area. Staff advised that they attend regular meetings, and this was confirmed by records maintained. However supervision records indicated that staff are not now receiving sufficiently regular one to one sessions. The deputy manager confirmed that it had not possible to keep up with this area, whilst the registered manager for the home remains suspended. Staff members spoken to advised that they generally felt well supported, but were most concerned about staffing numbers in the home. Bedford Road 7 DS0000010716.V365538.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, 39, 41 and 42. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although management arrangements are in place, insufficiently rigorous quality assurance procedures in place for the home, may compromise standards of care and support for people living at the home. Insufficiently rigorous health and safety procedures may also place people living and working at the home at risk of harm. EVIDENCE: Although a registered manager is in place for the home, they had been suspended from working at the home for approximately two months, without Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 24 prejudice. The deputy manager and another manager from within the provider organisation were covering management of the home. As the deputy manager works part time, she is covering three days weekly, with the other two days covered by the other manager. Staff spoken to indicated that they were working well with the interim arrangements, but there was noticeable low morale amongst the staff team. The deputy manager was hopeful that the issue concerning the registered manager would be addressed shortly, with several meetings recently held. Records maintained at the home indicated that unannounced visits undertaken on behalf of the provider organisation were still being undertaken sporadically and not monthly as required at previous inspections. Reports of these visits must be sent to the home and the local CSCI area office. This requirement is not restated in this report, however the CSCI is considering taking enforcement action to ensure compliance in this area. The deputy manager apologised for not having completed the current Annual Quality Assurance Assessment, due to time commitments. However it is required that this be completed without delay and returned to the CSCI to avoid the possibility of enforcement action being taken by the CSCI. A quality assurance audit must also be undertaken for the home including feedback from all stakeholders, with the results of this sent to the CSCI within three months, to ensure that the home is run in the best interests of people living at the home. Gas safety certificates, and portable appliances testing certificates were available for the home as appropriate. However the electrical installation certificate for the home was ‘unsatisfactory,’ and this must be addressed without delay. Records indicated that there are now more regular fire drills as required, including drills at different times of the day. However records showed that there are still some gaps in weekly fire alarm testing. This must be addressed as a matter of urgency for the protection of people living and working at the home. A warning letter is also being sent to the provider organisation to ensure that this requirement is met, to avoid the possibility of enforcement action being taken to ensure compliance in this area. Written evidence was seen to show that action had been taken to meet the requirements of the most recent London Fire Emergency Planning Authority (LFEPA) inspection of the home including ensuring that doors are self-closing. Bedford Road 7 DS0000010716.V365538.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X 2 2 X Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15(2) Requirement Timescale for action 25/07/08 2. YA12 16(2mn) 3. YA17 16(2i) The registered persons must ensure that all restrictions placed on service users e.g. storage of belongings outside of their room are clearly outlined in their care plans with the signed agreement of all relevant parties, to ensure that people’s rights are protected as far as possible. (Previous timescale of 01/02/08 not met). The registered persons 04/07/08 must ensure that activities offered to people living at the home are not cancelled due to staffing issues, to ensure that they are enabled to have stimulating lives. The registered persons 11/07/08 must ensure that clearer records are maintained of meals served to individual people living at the home, to ensure that their cultural and nutritional DS0000010716.V365538.R01.S.doc Version 5.2 Page 27 Bedford Road 7 needs are met. 4. YA19 12(1) The registered persons must ensure that more regular records are maintained of people’s weights and action is taken to address any discrepancies or significant changes, to ensure that the health needs of people living at the home are addressed appropriately. The registered persons must ensure that all medication is signed into the home. Discontinued medications should be removed from medication administration records to ensure that people’s medication needs are met safely. The registered persons must ensure that the carpet on the first floor hallway is thoroughly cleaned or replaced, and a new armchair must be provided in the identified person’s bedroom. (Previous timescale of 29/02/08 not yet met). The registered persons must ensure that there are no disruptions to the supply of hot water in the bathrooms for people living at the home. The extractor fan in the downstairs toilet must also be repaired/replaced with a more robust version, for the comfort of people living at the home. Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 28 11/07/08 5. YA20 13(2) 11/07/08 6. YA24 23(2bd) 08/08/08 7. YA30 23(2cj) 04/07/08 8. YA32 18(1a) 9. YA36 18(2) 10. YA39 24 The registered persons 04/07/08 must ensure that there are sufficient staff working in the home at all times, to ensure that people can undertake activities outside of the home and to address unforeseen emergencies. The registered persons 18/07/08 must ensure that all staff members are provided with regular individual supervision sessions at least six times annually and that these are recorded, to ensure that they provide people living at the home with support in line with best practice. 11/07/08 The registered persons must ensure that the current Annual Quality Assurance Assessment is completed for the home and returned to the CSCI. A quality assurance audit must be undertaken for the home including feedback from all stakeholders, with the results of this sent to the CSCI within three months, to ensure that the home is run in the best interests of people living at the home. Failure to comply with this requirement may result in enforcement action being taken against the home. The registered persons 04/07/08 must ensure that weekly fire alarm tests are carried out without any gaps, for the protection of people living and working at the home. (Previous DS0000010716.V365538.R01.S.doc Version 5.2 Page 29 11. YA42 23(4c(v)e) Bedford Road 7 timescales of 17/08/07 and 11/01/08 not met). Failure to comply with the requirement may result in enforcement action being taken against the home. The registered persons must ensure that a current satisfactory electrical installation certificate is available for the home, for the protection of people living and working at the home, and a copy of this certificate must be sent to the Regional CSCI office. 12. YA42 13(4) 25/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Bedford Road 7 DS0000010716.V365538.R01.S.doc Version 5.2 Page 31 - 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. 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