Inspection on 01/09/08 for Cecil Road (12)

This inspection was carried out on 1st September 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cecil Road (12) 11/06/07

Cecil Road (12) 28/09/06

Cecil Road (12) 02/02/06

Cecil Road (12) 12/07/05

Cecil Road (12) 02/03/05

Cecil Road (12) 29/06/04

Cecil Road (12) 01/03/04

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 08/11/2008.

CARE HOME ADULTS 18-65 Cecil Road (12) 12 Cecil Road Ilford Essex IG1 2EW Lead Inspector Harbinder Ghir Key Unannounced Inspection 1 and 9 September 2008 9:30 st th Cecil Road (12) DS0000025892.V361305.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 Cecil Road (12) DS0000025892.V361305.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. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cecil Road (12) Address 12 Cecil Road Ilford Essex IG1 2EW 020 8514 8689 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) mgauri@hotmail.com Mrs Veena Mehta Mrs Sumiran Sharma Mrs Veena Mehta Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate level of disability. Date of last inspection 11th June 2007 Brief Description of the Service: 12 Cecil Rd is a residential home registered to care for three younger adults with learning disabilities. The home is a terraced house in a residential area close to Ilford town centre, with good public transport links, a park and other community facilities. The house is an ordinary domestic property. All the residents’ occupy single bedrooms. Shared facilities include a lounge and a small dining area in the conservatory. A small garden is also available for the residents’ enjoyment. A bedroom is located on the ground floor as well as a toilet/ shower. There are two bedrooms upstairs plus a staff sleeping in room and a bathroom/toilet shared between the residents upstairs. The manager and staff ensure that people who use the service enjoy an active social life via membership of various groups and organisations. The staff take residents out on a regular basis to local pubs, cinema, restaurants as well as their chosen places of worship. Family and friends are welcome to visit at any time. A Statement of Purpose and Service User Guide are available upon request. The range of fees charged are from £687 to £787 per month. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the service experience good quality outcomes. This was an unannounced inspection undertaken by Regulation Inspector Harbinder Ghir on the 1st and 9th September 2008. The deputy manager of the home was available throughout the days of the inspection and feedback was provided to her at the end of the inspection. During the inspection the inspector was able to talk to one of the residents who was at home during the second part of the inspection. Staff on duty during this day were also spoken to and were also observed carrying out their duties. The London Borough of Redbridge who is the host authority for the service was contacted, inviting their comments on the service they are commissioning. They did not provide any feedback to be included at this inspection. The Commission for Social Care Inspection received a completed Annual Quality Assurance Assessment prior to the inspection. The inspector would like to thank everyone involved in the inspection process. What the service does well: What has improved since the last inspection? At the last inspection thirty five requirements were made in relation to updating the statement of purpose; the recording of complaints; health and safety; staff training; staff recruitment checks; care planning; healthcare; medication administration; environment and quality assurance system. All of these requirements have been complied with at this inspection, which demonstrates the service’s commitment to improving their service delivery. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose provides prospective individuals with the information they need to make an informed choice about where to live. The service completes comprehensive pre-admission assessments, to ensure they can fully meet the needs of prospective residents. Trial visits are offered to all prospective residents, to ensure residents have information on the services and facilities provided at the home. Each resident has an individual written contract of the statement of terms, to ensure they agree to the services provided at the home. EVIDENCE: The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the services supported by a service user’s guide. The statement of purpose has been reviewed since the last inspection complying with the requirement made at the inspection. It now has included information Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 9 on the staffing structure at the home and is supported by a service user guide, which is in picture format. It was not possible to examine up to date pre-admission assessments, as all three residents have resided at the home since 1997/1998. However, the service has a comprehensive pre-admission policy and procedure in place and admissions would not be made to the home until a full needs assessment has been undertaken. The policies and procedures highlighted that admissions to the home would only take place if the service is confident that staff have the skills, ability and qualifications to meet the assessed needs of prospective residents. New prospective residents would be able to visit the home as many times as they like and have an opportunity to stay overnight. Relatives and family would also be invited to visit the home. All residents were provided with a statement of terms and conditions. This set out simply and clearly and in detail about what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. The document was also provided in pictorial format to meet the communication needs of residents living at the home. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a comprehensive care planning system in place, which provides staff with the information required, to meet the needs of residents. The right for residents to exercise choice and control is promoted by the service and they are actively consulted on, and participate in, all aspects of life in the home. Risk assessments are undertaken routinely, to ensure residents are supported to take risks as part of an independent lifestyle, and are always updated according to residents’ changing needs. Residents’ financial interests are safeguarded, to ensure that records of residents’ outgoings and incomings of money are recorded correctly. Personal information was always safely and securely stored. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 11 EVIDENCE: Two care plans were closely examined. Care plans seen evidenced that the service involves individuals in the planning of care that affects their lifestyle and quality of life. Care plans were comprehensive; person centred and clearly set out residents’ health, personal and social care needs. Information was found specific to the religious, cultural and social care needs of residents and how the service was to meet these needs. The information provided in care plans was very detailed and individualised, and clearly recorded and described how residents wanted their needs met. For example one resident’s care plan informed how they would like to be communicated to. Care plans were written from the residents’ point of view and concentrated on promoting the independence and aspirations of residents. The documents also included information in picture formats, which is being further developed by the service, and included information on what residents are able to do independently and tasks they require assistance with. A key worker system also allows staff to work on a one-to-one basis and contribute to the care plan for the individual. Care plans were working documents and are reviewed on a six monthly basis or as and when required. In addition to this key workers also write a monthly key worker report. Evidence was seen of reviews taking place with care managers also involving the resident and their representatives. Reviews focused on asking what has worked for the individual, where progress is being made, achievements, and concerns and identified action points. Risk assessments were completed for residents and identified risk areas in care plans including, the event of a fire, risks that may be presented by the building, mobility, falling and wandering. Assessments included clear guidelines for staff to follow in managing risks posed to people who use the service. Risk assessments were reviewed regularly and amended. Daily case recording notes were examined which are linked to the care plan and focus on the specific needs of residents rather than recording information in a general manner. Each resident has a personalised case recording sheet which may focus on their challenging behaviour, their diet or the risks they are posed to, which provided specific information about each resident which is used to monitor their care needs or their behaviour on a on-going basis. Residents were involved in the daily running of the home as far as their abilities allowed. A rota was also seen in the homes kitchen which described what days residents were responsible for setting the table, participating in cleaning tasks, clearing and laying the table and cooking. Residents were also supported to bring their laundry down and place it in the washing machine. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 12 Residents’ rights to make choices were actively promoted; by them being supported to choose what to wear, to eat and which activities they would like to participate in. Resident’s personal information was safely and securely stored in the home’s office, which was kept confidential. The financial records of residents were viewed. All amounts were accounted correctly and were in order. There were clear systems to record outgoings and incomings of money, which were audited regularly by the registered proprietor. Cecil Road (12) DS0000025892.V361305.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): 11, 12, 13, 14, 15, 16, 17 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are provided with support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life, promoting their opportunities to be part of the local community. Residents are offered meals that promote their choices and respect their individual preferences. Residents are supported to maintain family links and relationships inside and outside the home. EVIDENCE: Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 14 The service has a strong commitment to enabling residents to develop and maintain their skills, including social, emotional, communication, and independent living skills. Individuals were supported to identify their goals, and work to achieve them. All three residents attended specialist day centres five days a week where they completed activities such as gardening, bowling and other leisure activities. One resident was in paid employment, working one afternoon in the cafeteria at their local day centre. Another resident worked for SCOPE. Residents participated in shopping trips, going to eat out or participated in activities of their choice in the evenings and on the weekends. A resident who had a talent for painting was supported to paint at the home and the home had displayed their work around the premises. The deputy manager also informed that they are supporting the resident to sell their artwork. People who use the service had the opportunity to develop and maintain important personal and family relationships. Residents were supported to contact family whenever they wished. Evidence was seen of residents supported to visit and stay with family. One resident spoken to spoke very positively about the care provided at the home. They said, “ Yes, I like living here, I’ve been here a long time.” When asked about choices offered at the home, the resident replied, “They ask me what I want to wear and I say I want that.” They further informed, “On the weekends, I sometimes go out and go shopping or go to the bank and get some money out. Sometimes my family visits. My sister took me out not long ago and we went to the pub.” The home provides meals, which are varied and nutritious and meet the dietary needs of residents. There was plenty of fresh fruit and vegetables at the home. Residents choose their meals from a four weekly menu or choose something, which is not on the menu, which staff prepares. There is also a separate menu devised for a resident who is diabetic to cater for their specialist diet. Evidence was also seen of residents going out to local restaurants and being provided with take away meals of their choice. Adequate kitchen equipment was provided and a new set of colour coded chopping boards had been purchased to reduce the risks of infection. Fridge and freezer temperatures were also taken on a daily basis, meeting the requirement made at the last inspection. However, not all opened foods in the fridge were labelled with the date of opening, which would place the risk of food not being used within the periods specified on the items. Therefore, it is Recommendation 1 that all foods are correctly labelled with the date of opening, to reduce any risks of infection. Cecil Road (12) DS0000025892.V361305.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, 21 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive personal support and care in the way they prefer and require, but the service must ensure that residents’ personal care and hygiene is always maintained. Medication practices ensure the safety of residents. The ageing, illness and death of people who use the service are handled with respect and as the individual would wish. EVIDENCE: Residents at the home receive personal care and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Each resident has a devised health action plan which identifies the healthcare needs of residents including specialist health, nursing and dietary requirements, which are clearly recorded and act as an indicator of change in health requirements. The plan also identified residents’ daily routines including the type of support they need in Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 16 relation to personal hygiene and according to their level of care needs. However, when speaking to a resident, black residue was observed under their nails. It is Requirement 2 that the service ensures that personal care is regularly attended to and maintained. Residents underwent monthly weight checks and each resident’s nutritional intake was recorded on a daily basis to monitor and ensure their nutritional needs were being met, as identified by their care plan. All residents have a designated key worker to promote their privacy and dignity, and all personal care is provided in private. Attention is paid to personal preferences in relation to the provision of personal care, for example whether one prefers a shower or a bath. Personal support takes account of individual preferences and residents’ choice of dress and appearance is respected. Residents were well dressed and groomed. Residents are supported by staff to attend appointments with healthcare professionals and their health is closely monitored and prompt referrals are made. There was evidence of staff taking female residents to well women checks and the involvement of multli-disciplinary healthcare professionals where required were made to dentists, chiropodists, GP’s and community psychiatric nurses. Steps have been taken to find out the wishes of residents in the event of their death, including contacting relatives or representatives where the resident is unable to express their views. There are policies and procedures for staff to follow in the event of a death; to ensure the death of a resident is handled with respect and as the individual would wish. Medication administration records (MAR) were closely examined. Medication records were fully completed, contained required entries, and were signed by members of staff. The medication file contained photographs of each individual and a medication pen picture. There were also records of signatures by family receiving medication and staff accepting medication when residents were away for overnight stays with family, complying with the requirement made at the last inspection. The service has also produced a written policy on any medication leaving the home that includes the procedures to be followed and the precautions to be taken, in compliance with Care Homes Regulations 2001 and The Administration & Control of Medicine Guidance, complying with the requirement made at the last inspection. Each resident had signed a consent form, giving the service permission to support them to administer their medication and temperature controlled medication was stored in a locked container in the fridge. All members of staff had received training in medication administration and specialist training in insulin administration. All medication received by the home was arranged in blister packs with clear descriptions displayed for each medication on each pack, to reduce the risks of any medication errors occurring. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 17 Cecil Road (12) DS0000025892.V361305.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, 23 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured their views are listened to and acted on. The service records all complaints and concerns to ensure any dissatisfactions with the service regardless of source are actioned. All staff has received up to date training in Safeguarding Adults, which ensures the protection of residents. EVIDENCE: People who use the service are supplied with a complaints procedure, which is clear, concise and easy to follow and was displayed around the home. The procedure also clearly stated that the Commission for Social Care Inspection can be contacted at any time or stage of complaint being made. A complaints logbook is kept by the home, which was viewed. No formal complaints have been received by the home since the last inspection. The Commission for Social Care Inspection has not been informed of any complaints. Evidence was also seen of verbal concerns recorded by the service, however the service did not record the actions they took to investigate and resolve the concerns. A recommendation in relation to these findings will stated as Recommendation 2. Since the last inspection all staff have attended Safeguarding Adults training which is also covered in the induction programme. The service has comprehensive Safeguarding Adults procedures and protocols in place. The service has obtained Safeguarding Adult procedures devised by The London Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 19 Borough of Redbridge. There was also comprehensive guidance for staff on how to record incidents of abuse using body charts and preserving evidence. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 20 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, 25, 26, 27, 28, 29, 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely living environment, enhancing residents’ comfort. EVIDENCE: Cecil Road is a terraced house in a residential area close to Ilford town centre, with good public transport links, a park and other community facilities. The house is an ordinary domestic property. All the residents occupy single bedrooms. Shared facilities include a lounge and a dining area in the conservatory. A garden is also available. A bedroom is located on the ground floor as well as a toilet/ shower, which has been allocated to a resident with poor mobility. There are two bedrooms upstairs plus a staff sleeping in room and a bathroom/toilet shared between the residents upstairs. Since the last inspection the service has decorated the premises, complying with the requirements made at the last inspection. They have painted all Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 21 communal areas and residents’ bedrooms. They have laid new carpets throughout the home and have replaced the first floor bathroom suite and decorated the ground floor shower room. New furniture has been purchased for the living and dining room and residents’ have also received new beds and one resident has had new fitted wardrobes in their bedroom. The resident was spoken to during the inspection and informed, “I like my new wardrobes, and they are very nice. My clothes are all hung up neatly.” The staff sleeping room has also had its bed replaced with a new bed. Members of staff also commented positively on the environmental changes the have taken place at the home. “There have been big changes at the home. The home looks lovely. The residents are happy then we are happy, so everything is good” said a member of staff. The service stated in their Annual Quality Assurance Assessment that they would like “to encourage service user’s to make more use of the garden.” The statement was evidenced by the changes made to the homes rear garden, which now provides adequate garden furniture and was well maintained. The service is commended for making improvements to the environment, which now ensures that residents live in a comfortable and homely environment. Specialist equipment for residents was provided where required and bathrooms and toilets were fitted with appropriate aids and adaptations to meet the needs of people who use the service. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 22 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, 36 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment practices are robust and ensure residents are in safe hands at all times. Adequate staff training is provided to all care staff, to ensure they are equipped with the skills and are competent to do their jobs. The service has a good skill mix of staff, ensuring adequate numbers of staff are on duty to meet the needs of residents. EVIDENCE: Three staff files were closely examined, which were all in good order. No new members of staff have been recruited since the last inspection. References and Criminals Records Bureau checks had been obtained for all three members of staff. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 23 Staff rotas evidenced there are sufficient numbers of staff on duty to meet the needs of residents during the day. The service has a stable workforce and does not use agency staff. There are always two members of staff on duty during the day and one sleep in member of staff on duty at night. However, it is recommended that the registered manager completes lone working risk assessments to ensure people working at the home and residents are safeguarded. This will be stated as Recommendation 3. Staff supervision records evidenced that staff were supervised at least six times a year, ensuring staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. Members of staff spoken to also commented that they were supervised regularly. Staff meetings are organised on a monthly basis and staff spoken to confirmed that they always take place, allowing them an opportunity to discuss issues or any concerns they have. Yearly appraisals are also completed with all members of staff to ensure staff development is an integral part of service delivery. Files viewed all evidenced that staff had been on induction programmes and all received ongoing training, including training in Safeguarding Adults, First Aid, Hygiene, Health and Safety, Risk Assessments, Fire Safety, Infection Control and Moving and Handling. 80 per cent of the staff team are working towards a National Vocational Qualification at level 2 or above. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 24 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, 42 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from an experienced manager who recognises their needs and adequately manages the home. The systems for service user consultation are in place, which also include the views from stakeholders to ensure the home is run in the best interests of residents. The welfare of staff and residents is promoted by the home’s policies and procedures. EVIDENCE: The registered and the deputy manager have completed a NVQ level 4 qualification. The deputy manager has also attended various workshops in Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 25 management training provided by the London Development Agency. The registered manager communicates a clear sense of direction, leadership and openness. The manager trains and develops staff that are generally competent and knowledgeable to care for people who use the service. The service works in partnership with families or close friends, as appropriate and professionals. One member of staff spoken to said “The manager supervises me regularly. I like working here, they really do listen to us if there is a problem, but there are not many problems here.” Another member of staff informed “The management are very nice here, whatever we need they provide.” Annual quality assurance systems are in place, and questionnaires completed by family and their representatives were seen. Health professionals, social services and other stakeholders in contact with the home were involved in quality assurance surveys, to ensure their views were sought on how the home is achieving goals for residents. The results of surveys that had been completed had been analysed. Health and Safety records were inspected. All documentation was in order and appropriately completed. The home works to clear health and safety policy. Certificates viewed included certificates confirming electrical installation, gas safety and employers liability insurance. Fire drills were also completed regularly the time it took to evacuate the building was recorded each time. Water temperature checks throughout the home were only completed monthly. The Health and Safety Executive in their Health and Safety in Care Homes guidance informs that water temperature checks must be completed on a weekly basis. This will be stated as Requirement 1. A completed Annual Quality Assurance Assessment was received before the inspection and was supported by a wide range of evidence. It informed of the changes the service has made and where they still need to make improvements. Monthly regulation 26 visit reports were available to view at the home. Visits had been completed on a monthly basis and provided comprehensive information on the day-to-day operations of the home. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 26 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 27 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 YA42 Regulation 13 (4) (a) Requirement The Registered Persons must ensure that water temperature checks are completed on a weekly basis as informed by The Health and Safety Executive in their Health and Safety in Care Homes guidance. The registered persons must ensure that the personal care of residents is maintained. Timescale for action 31/10/08 2 YA18 12 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 Refer to Standard YA17 YA22 YA31 Good Practice Recommendations It is recommended that all foods are correctly labelled with the date of opening, to reduce any risks of infection. It is recommended that the service records the actions they took to investigate and resolve any concerns recived by the service. It is recommended that the registered manager completes lone working risk assessments to ensure people working at the home and residents are safeguarded. Cecil Road (12) DS0000025892.V361305.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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