Inspection on 23/11/06 for Clara Nehab House

This inspection was carried out on 23rd November 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Clara Nehab House 31/05/07

Clara Nehab House 10/10/05

Clara Nehab House 17/05/05

Clara Nehab House 31/01/05

Clara Nehab House 28/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Clara Nehab House 13-19 Leeside Crescent Golders Green London NW11 0DA Lead Inspector Tony Brennan Key Unannounced Inspection 23rd November 2006 12:00 X10015.doc Version 1.40 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 Clara Nehab House DS0000010422.V303580.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 Older People. 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. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clara Nehab House Address 13-19 Leeside Crescent Golders Green London NW11 0DA 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 8455 2286 020 8455 2120 Leo Baeck Housing Association Limited Mr David Lightburn Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 & 16 June 2006 Random Unannounced Inspection Brief Description of the Service: Clara Nehab House is registered to provide care for twenty-five older people. The Leo Baeck Housing Association operates the home. The accommodation is provided on three floors in twenty-five single en suite bedrooms. The lounge/dining room and an additional lounge is on the ground floor. The home is located in a residential area with shops and access to public transport close by. The original aim of the home was to provide care for people who had suffered Nazi oppression. Service users admitted to the home more recently may not have had that direct experience but choose to live there because the background ethos is relevant to their personal experience as the home maintains practices that meet the needs of service users from a Jewish background. The fees are £675 a week. This report is available through the internet. Copies may also be obtained from the provider of this service. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken as part of the annual inspection programme. The inspection took place over one day. The registered manager, David Lightburn, assisted the inspector. The inspector received comment cards from the service users and professionals who live, or are connected with Clara Nehab House. The inspector spoke with four service users and three staff. The inspector observed care practice and staff interaction with service users. The inspector toured the building and examined a number of records relating to the care, health and safety and management of the home. The inspector would like to thank the registered provider and staff who assisted him by answering questions about the running of the home. The inspector would also like to thank people who live at the home and their representatives for commenting on the service. What the service does well: What has improved since the last inspection? Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 6 Nine areas for improvement were identified at the last inspection and six were addressed. An assessment had been carried out to ensure that the hairdressing facilities are safe for those who live at the home to use. The complaints record now contains a full report on an incident of theft investigated by the home. A refurbishment plan has been put in place and is being actioned to improve the environment for those who live at the home. A fire drill has been carried out to ensure the safety of people who live at the home and staff. The heating system has been fully serviced. Contractors have been contacted to discuss the time scales for addressing all the issues outlined in the maintenance plan. What they could do better: Thirteen areas for improvement were identified at this inspection. Care plans need to provide more details of the actions to meet the needs of people who live at the home. Care plans must provide more details of the personal preferences and choices of people who live at the home. Care plans are to be reviewed and changes identified. The needs of people who live at the home must be recorded in their care plans. A risk assessment is to be carried out of the oxygen cylinder in bedroom 51. A sign needs to be put in place to alert people who live at the home and staff to the fire hazard from the oxygen cylinder in bedroom 51. The risk of developing pressure sores and the nutritional needs of people who live at the home need to be assessed. All extractor fans need to be in working order to ensure the comfort of people who live at the home. The maintenance issues identified in this report regarding bedroom 33 must be addressed to ensure the comfort and safety of the person whose bedroom it is. A review of the needs of people who live at the home and staffing levels to ensure that they are supported by sufficient numbers of staff during morning shifts must be carried out. 50 of staff must achieve the National Vocational Qualification at level 2 in care to ensure that staff have all the skills to meet the needs of people who live at the home. The needs of the people living in the sheltered housing bungalows need to be reviewed by the placing authority to ensure that the correct level of domiciliary support is provided. One requirement made at the last inspection has not yet been met and has been restated in this report, with a new timescale for compliance. In the ‘Timescale for Action’ column, the date in ordinary type relates to the timescale given at the last inspection. The date in bold type relates to the new timescale. Further information about unmet requirements can be found in the relevant section. Unmet requirements impact upon the welfare and safety of service users. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. Clara Nehab House DS0000010422.V303580.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. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to admission to the home to ensure they receive the care and support they need. Not all the needs of service users are identified and met. EVIDENCE: Comment cards from service users and their representatives confirmed that they had been given information on the home prior to admission which outlined the care and support provided. A service user who was case tracked and had recently come to live at the home told the inspector “I came ad saw the home before deciding to move in. The manager answered all my questions”. The inspector found that the service users case tracked had been assessed prior to their admission to the home. Another service user who was case tracked said, “I was asked about the help I needed”. The inspector found that the needs of the service user were identified in her initial assessment. Cultural and religious needs were identified as part of the initial assessment process. One service user case tracked explained that he is an Orthodox Jew. The service user explained that the registered manager and staff had supported him to practice his beliefs and respect his choice to pray alone. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 10 At the random inspection of the 07/11/06 a requirement was made for the needs of the service users in the sheltered housing bungalows to be reviewed to ensure that they receive the domiciliary support they need. The registered manger explained this was still to be done. There are a number of issues in the outcome area health and personal care that need to be addressed to ensure the needs of service users are met. The inspector found that the risk assessments for nutrition and pressure sore care were not in place. Service users care plans were not detailed. Care plans need to be reviewed and changes identified to meet the needs of service users must be recorded. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal, social and medical care needs are not fully planned for. Service users are fully protected by safe procedures for handling medication. Service users right to privacy is supported. EVIDENCE: Comment cards received from relatives and service users confirmed that they were happy with the care provided. One service user’s care plan case tracked addressed the needs identified in their initial assessment. Three major areas of need identified concerned the wishes of the service user to maintain his independence, the management of his Parkinson disease and a food allergy. The service user’s care plan outlined the service user’s wishes. Other information on the support that the service user required was outlined in his care plan. The service user told the inspector, “I have a food allergy and staff understand what I can and can’t eat”. The service user’s care plan was focused on maintaining his independence and was person centred. Staff spoken to understood the needs of this service user. The service user’s religious needs were recorded in his care plan. Staff spoken to understood that he wished to pray in private and understood how to support him to do this. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 12 Another service user case tracked who had also come to live at the home recently confirmed that staff had asked her about the support she needed. The service users care plan was found not to provide detailed information on her needs or how they should be met. Although the service user could explain her personal preferences these were not recorded in her care plan. There was no risk assessment for manual handling in place. The service user had an oxygen cylinder in her room for her personal use. The inspector observed this was placed on the floor and could constitute a trip hazard. There was no risk assessment for the oxygen cylinder and guidance on its safe use. The inspector found that there was no sign to alert service users and staff that oxygen was in use and constituted a fire hazard. An anonymous complainant had raised concerns regarding the care of a named service user. The inspector case tracked this service user and found that not all her needs had been addressed fully. The service users notes showed that she was very frail and had a repeating tissue viability need. Although the district nurses were dealing with this, no risk assessment had been carried out by the home to identify the degree of risk. The service user had not been referred to a specialist, such as the tissue viability nurse. The service user had also been identified to have a poor diet. Daily notes showed that the service user had not been eating. There was no nutrition assessment to identify the level of risk for the service user. The service users care plan stated that she mobilised with a Zimmer frame. However, daily notes stated that the service user was not able to weight bear. Care plans need to be reviewed and changes identified to the needs of the service user must be recorded. Barnet Social Services Department had recently reviewed the service user and identified that the service user had complex and changing needs. There had been concerns raised that the service user was in need of nursing care. The service user has subsequently been admitted to hospital with a chest infection and related complications. Service users case tracked had records of medical support. Service users spoken to commented that they receive medical care when they needed it. A service user said, “since coming to live here I have seen the dentist and got new teeth”. Service users case tracked also had records of medical support provided from the dentist, chiropodist and optician. The inspector observed staff administering medication to service users, this was done safely and in way to ensure that service users understood what was happening. The inspector found that the medication policy was complete and contains all the necessary guidance to ensure that a safe system for the management of service users medication was in place. The inspector examined the medication records for medicines received, administered and returned, and found these were complete. The General Practitioner had been consulted to ensure that medication was appropriate to the health needs of the service users. A record is maintained of the temperature of the areas where Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 13 medication is stored. This showed that the temperature was below 25ºC. Staff spoken to confirmed that they had received training in how to administer medication safely. The inspector found there was a list of the names of those staff that are trained to administer medication. Certificates were available to confirm that staff had received the required medication training. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with varied activities to meet their needs. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. The menu reflects the preferences of service users and offers a balanced diet. EVIDENCE: An anonymous complaint had alleged that service users were not provided with activities. The inspector had seen a range of activities provided at previous unannounced inspections. A random inspection carried out on the 16/06/06 found that activities were being provided. A service user confirmed that they had been on outings to the theatre and to Kenwood. Comment cards received from service users confirmed that they felt that sufficient activities are provided. The inspector observed that activities were provided on the day of the inspection. This included group work and a discussion. A service user said, “activities are provided every day and you can do what interests you”. The service users spoken to confirmed that they had regular visits from the Rabbi and that Jewish festivals are celebrated. A service user said, “the Rabbi visits every Saturday and on holydays. I am happy with this”. The inspector saw that service users could choose how to spend their time. The inspector observed that service users spent time in their Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 15 bedroom reading or relaxing. Staff were observed spending time talking to service users. A service user said, “I can see visitors in private and can choose where I see them”. The inspector observed that visitors and service users were offered the choice to spend time in private. Staff spoken to understood the need to support service users to make choices about how they wished to live. Comment cards received from service users confirmed that they were happy with the food provided. The inspector found that the menu showed that main and second choice of lunchtime meal was offered each day. A service user said, “the food is good”. Another service user said that a choice of meals was on offer. The service user commented, “there has been an improvement to the suppertime menu. More choices are being provided”. The cook explained that the menu had been reviewed to ensure that it provides a variety of meals. The General Practitioner and a Dietician’s opinions have been sought of the nutritional balance of the meal provided. The inspector observed lunch and saw that meals were well presented. Food is served in tureens to each table, with the service users able to choose how much they wish to eat. Support was provided in a way that gave the service users the opportunity to eat at their own pace. Food was cut and staff took time to feed service users who needed support. Sufficient staff were available to support all service users. A service user said “I spoke to the cook before coming to live here. They provided me with kosher food”. The inspector spoke with the cook who explained how she prepared food in line with kosher rules. The cook explained that food is sourced from kosher shops. The inspector saw that there were separate fridges for food products that could not be stored together. On the day of the inspection the cook had prepared a dessert from a recipe provided by one of the service users. The menu was seen to include traditional recipes that reflect the cultural backgrounds of the service users living at the home. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Comment cards received from service users showed that they understood how to make a complaint. The complaints policy explained how to make a complaint and how it would be dealt with. A service user said, “I can always go and complain to the office. I feel confident they would deal with any concerns I might have”. At the random inspection of 7/11/06 it was found that a complaint and the action taken to resolve it had not been recorded. The inspector checked the complaints record and found this complaint had now been fully recorded. The complaints record now shows actions taken to resolve all complaints. There have been a number of complaints from one anonymous complainant since the last inspection. The Commission had investigated the complainant’s allegations and the findings are referred to in this report. A service user said, “staff are trustworthy and treated you well”. There were comprehensive policies on handling abuse and protection. Staff spoken to were clear about the signs of abuse and how suspected abuse should be handled. The inspector found that staff have received training on POVA since the last inspection. There had been one adult protection issue raised since the last inspection concerning the care of a specific service user. This has been addressed and no abuse was found to have taken place. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home that does not provide a safe environment. The home is clean and hygienic. EVIDENCE: An anonymous complainant had raised a number of issues relating to the maintenance of the home. These had been investigated at the random inspections of the 16/06/06 and 07/11/06. The inspector found that the providers had installed the sink on the advice of the hairdresser and a suitable chair will be purchased, to ensure that there are appropriate and safe facilities for service users. The registered persons were required to ensure an occupational therapist assessment is carried out, which had been done. The inspector saw the assessment from the occupational therapist, who confirmed that the current basin and chair used for washing service users hair were “suitable for most service users”. The occupational therapist had advised that any service user with specific needs would have to be assessed individually. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 18 The anonymous complainant alleged that the majority of the extractor fans in the bathrooms were faulty. At the random inspection of the 16/06/06 it was found that with the exception of two extractor fans, all others were working. In addition, all the extractor fans in the 25 bedrooms were found not to be working. A requirement was made that all exactor fans must be in working order. At this inspection the registered manager was able to show that there are now only three extractor fans not working and awaiting replacement. On the day of the inspection the inspector found that with the exemption of the three extractor fans identified as not working, the rest are now working. At the random inspection of the 07/11/06 in response to an anonymous complaint a requirement was made to ensure that the provider developed a refurbishment plan detailing when all identified areas of maintenance would be addressed. A copy of this had been sent to the Commission. The inspector discussed the refurbishment plan with the registered manager. The registered manager explained that the area of flooring in bedroom 8 which had been found to be flexible had been repaired. The inspector checked the floor in bedroom 8 and found that it had been repaired. The registered manager explained that the en suite toilet and shower in bedroom 77 had been redecorated and new flooring had been laid. The inspector checked bedroom 77 and found this to be the case. The radiator in bedroom 78 had been found to be too hot and could not be controlled to lower the temperature. Since the service user who occupied the bedroom had been admitted to hospital, and would not be returning to Clara Nehab the inspector asked that the registered manager agree not to admit a new service user to this bedroom until the heating problem had been addressed. The registered manager agreed to do this and wrote a letter to confirm this. The registered manager explained that he would be arranging for the fitting of a thermostatically controlled combined heater/air conditioner unit. The existing radiator will be removed. The registered manager explained that half of the thermostatic valves had been replaced. The inspector saw records that confirmed this. The registered manager said that he has started to review the layout of the kitchen and will agree a refurbishment plan once this is complete. The inspector saw that a new dishwasher and cooler had been fitted in the kitchen. Other areas of the maintenance plan have yet to be addressed. Dates for completion have been planned. The inspector explained further random inspection visits would be carried out to confirm that all the work is completed. The registered manager explained that he will be meeting with the contractor to discuss maintenance issues and has already arranged for the central heating system to be fully serviced. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 19 The inspector toured the building and found that service users bedrooms were personalised. A service user case tracked said, “I brought all the things I wanted when I moved in”. The inspector saw that records of maintenance were being maintained. The Care Manager explained that she carries out weekly room checks. The inspector found that in bedroom 33 the shower tray had no panels around it. There were also some areas where paintwork was chipped. These issues were recorded in the maintenance record and the Care Manger explained that they would be dealt with soon. The home has been adapted to meet the needs of service users. There are raised toilet seats and accessible baths. Records showed that regular maintenance checks of the chair lift had been carried out. The inspector saw that the home was clean. The inspector found that all bathrooms and toilets had liquid soap and paper towels in them. Staff spoken to understood how to prevent cross infection when assisting service users with personal care tasks. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff are not available at all times to meet service users needs. Staff do not have all the skills to meet all the assessed needs of service users. Service users are protected by the home’s recruitment practices. EVIDENCE: The registered manager explained that since the last scheduled inspection a fourth member of staff is on duty. Rotas showed this level of staffing had been maintained. As part of the random inspection of the 07/11/06 it was found that an additional staff member is required from 8-12 in the morning due to the increased care needs of service users. A requirement was made that staffing levels be reviewed. A service user told the inspector, “staff have a lot to do”. The registered manager explained that he has started to carry out a review of staffing levels using a staffing analysis tool. The registered manager explained he would repeat this monthly. This will ensure that there are always an enough staff to meet the needs of service users. The registered manager explained that a full time member of staff would be leaving soon. The registered manager explained that he would be using the hours from this vacant post to provide for an 8-12 shift each day. The inspector spoke with staff and examined training records that confirmed they had received the required statutory training. A service user commented, “staff understand how to help me”. Staff who spoke to the inspector explained that they had received training on the Jewish culture. Staff confirmed there was a range of training provided. Service users spoken to confirmed that staff Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 21 were respectful and supportive of their religious needs. Training records showed that staff had recently attended training on helping service users to maintain their mobility as well as developing key working issues. The Care Manager explained that there had been ongoing issues with the provider of National Vocational Qualification training. The home has now found a new provider for this training. As a result of this the home still needs to reach the target of 50 of staff achieving National Vocational Qualification in care at level 2. The inspector examined files of staff that had recently started work at the home. These were found to be complete and contained all the required information. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager does have the necessary qualifications to manage the home effectively and in the best interests of service users. Service users are consulted about the quality of the service provided and encouraged to make suggestions for improvement. Service users financial interests are protected by the home’s procedures. Staff are supervised to ensure that they are able to meet the needs of service users consistently. Service users and staff are protected by the home’s health and safety procedures. EVIDENCE: The inspector found that the registered manager has the necessary skills and qualifications to meet the needs of service users. The registered manager has 30 years experience in social care and related work. The registered manager is a qualified nurse. The registered manager explained he has recently completed a Master’s degree and holds a postgraduate diploma in health and social care. The registered manager has also recently completed fire and Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 23 health and safety training. A service user commented, “I have spoken to David (the registered manager) and he is helpful”. The home has a system for obtaining the views of the quality of the service it provides and ensures that any areas for improvement are addressed. A survey of the views of service users, relatives and professionals was in place. Staff meetings are taking place. At the inspection of the 07/11/06 the monies held on behalf of service users was checked and found to be in order. The registered manager explained that the service user’s family manages the individual’s finances. Appropriate policies are in place to safeguard the financial interests of service users. Both the registered and care manager explained that regular supervision has been provided for all staff since the last scheduled inspection. The inspector spoke with staff who confirmed that they had received regular supervision. At the random inspection of the 07/11/06 it was found that there had not been a fire drill since October 05. A requirement had been made that a fire drill must take place by the end of the week of the inspection and evidence of this to be sent to the Commission. This had been done and a copy of the record of the fire drill had been sent to the Commission prior to this key inspection. The registered manager confirmed that fire drills would be carried out regularly. In addition, as part of the maintenance plan for the home, the upgrade of the fire alarm system will be completed. The registered manager explained that work had already commenced on this and the upgrade would be completed. The inspector found that the portable fire equipment had been checked and was all in working order. The fire risk assessment includes an assessment of all the potential fire risks in the home, except the oxygen cylinder for which a requirement is made to safeguard service users and staff. All health and safety policies were available. Certificates for gas, legionella and electrical testing were in date. COSHH guidance was in place and chemicals were stored safely. The inspector discussed health and safety issues with staff and they demonstrated their understanding. The home has an effective system for monitoring accidents. The inspector found that the temperature of cooked food, fridges and freezer are recorded. Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 25 yes 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. 2. Standard OP4 OP7 Regulation 14,15 15(1) Requirement The registered persons must ensure that all the needs of service users are met. The registered persons must ensure that care plans provide details of the actions to meet the needs of service users. The registered persons must ensure that care plans detail the personal preferences and choices of service users. The registered persons must ensure that care plans are reviewed and any changes identified to the needs of service users must be recorded in their care plans. The registered provider must ensure that a risk assessment is carried out of the oxygen cylinder in bedroom 51. The registered persons must ensure that a sign is put in place to alert service users to the fire hazard from the oxygen cylinder in bedroom 51. The registered persons must ensure that service users risk of developing pressure sores is DS0000010422.V303580.R01.S.doc Timescale for action 01/01/07 30/01/07 3. OP7 15(1) 30/01/07 4. OP7 15(2)(b) 30/01/07 5. OP8 13(4)(a) 01/01/07 6 OP8 13(4)(a) 01/01/07 7 OP8 13(4)(c) 30/01/07 Clara Nehab House Version 5.2 Page 26 8 9 OP8 OP19 13(4)(c) 23(2)(P) 10 OP19 23 11 OP27 18(1)(a) assessed. The registered persons must ensure that the nutritional needs of service users is assessed. The registered persons must ensure that all extractor fans are in working order. Previous timescale of 30/11/06 was not met. The registered persons must ensure that the maintenance issues identified in this report regarding bedroom 33 are addressed. The registered persons must review the service users needs and staffing levels to ensure that they are supported by sufficient numbers of staff during morning shifts. 30/01/07 01/01/07 30/01/07 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP4 Good Practice Recommendations It is recommended that the needs of the service users in the sheltered housing bungalows are reviewed by the placing authority to ensure that the correct level of domiciliary support is provided. The registered persons should ensure that 50 of staff achieve NVQ at level 2 in care. 2 OP28 Clara Nehab House DS0000010422.V303580.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Clara Nehab House DS0000010422.V303580.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. 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