Inspection on 27/02/06 for Coleraine Road 30 & 37

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Coleraine Road 30 & 37 09/01/07

Coleraine Road 30 & 37 09/08/05

Coleraine Road 30 & 37 04/05/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Coleraine Road 30 & 37 London N8 0QJ Lead Inspector PPeter Illes Unannounced Inspection 27th February 2006 09:45 Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 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 Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 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. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Coleraine Road 30 & 37 Address London N8 0QJ 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 8888 4348 020 8888 4348 Mr Edward William Marcus Mr Edward William Marcus Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Limited to 8 adults with a learning disability (LD) not to exceed 4 accommodated at 30 Coleraine Road and 4 accommodated at 37 Coleraine Road. 9th August 2005 Date of last inspection Brief Description of the Service: The Coleraine Project is made up of two mid-terraced houses located opposite each other in Coleraine Road. The project is located in a residential area of Wood Green North London, less than a 100 yards from Wood Green High Road and the extensive shopping, transport and leisure facilities that the area has to offer. The two houses, which comprise the project, are registered as one care home offering personal care and support for up to eight service users whose primary need for care is that they have a learning disability. There are four bedrooms in each house, and the communal areas comprise of a lounge, kitchen diner, utility room and back garden. Both houses have a ground floor toilet, and first floor bathrooms and additional toilet. Neither house has been adapted to provide for service users with a physical disability. The registered provider both owns and manages the home. The staff team of the project work in both houses to ensure that they become familiar to all the service users. The aim of the service is to provide a home, which encourages and supports service users to build a home life and participate actively in a lifestyle, which reflects their values and preferences. In addition, the home aims to promote the independence and integration of service users with the local community from a secure and homely base. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately two and a half hours. The senior support worker for the home, Mr Kamrul Hassan-Shiblee, was present or available throughout. Mr Hassan-Shiblee has been delegated significant areas of responsibility for managing the home on a day-to-day basis. He was extremely knowledgeable about both the management issues in the home and the needs of the service users. There were eight service users accommodated at the home and no vacancies. The inspection consisted of: meeting four of the service users and independent discussion with two of them, detailed discussion with the senior support worker and discussion with two other staff members, one of them independently. Further information was obtained from a tour of the premises and a range of documentation kept in the home. What the service does well: This is a well managed and run home that provides high quality support and care for service users that they appreciate. Some of the service users have complex needs and the home has developed some very good quality documentation to assist in how service users can be supported in meeting these. The home is sensitive to service users cultural and religious needs. The home is involving service users at all stages in working on more effective ways of helping them as individuals gain the skills and confidence to be more independent in their daily lives. Service users continue to enjoy a wide range of activities including opportunities to develop their skills in the home, in the community and on exciting holidays abroad. Service users are due to go on holiday to Borneo in April 2006 and are very much looking forward to this. Staff enjoy a wide range of training and development opportunities including effective induction and other core skills training when they are first recruited. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 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 Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective service users can be confident that their aspirations and needs will be assessed to ensure that these can be met when they move into the home. EVIDENCE: One new service user had been admitted to the home since the last inspection and the file for this person was inspected. This service user had been admitted from a specialist health facility and the file showed a comprehensive range of multi-disciplinary assessment information. The record of a recent Mental Health Review Tribunal and the current legal status of the service user under mental health legislation informed and were included in this assessment information. There was also evidence that the home had undertaken significant assessment work of its own to make sure that it had the necessary resources to assist meet the service users needs. From records seen and from discussion with staff it was also evident that work had been undertaken to minimise any potential disruption to other service users and to facilitate a smooth transition for all. The service user was spoken to independently and was very positive about the admission process and about the home. The service user stated that they felt that things were going well at the home and indicated that they liked the staff and appreciated the freedom to make decisions for themselves. The service user was very clear and appreciative that the opportunity to make decisions about their daily life and the related freedom to make real choices was not available at their previous accommodation. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Service users assessed and changing needs as well, as their personal preferences, are well documented in their care plans and person centred plans to assist the home’s staff and relevant others meet these needs and wishes. Service users are supported to make informed decisions about their daily lives with any restrictions being agreed with them and recorded. Service users are also supported to take appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: Care plans for two service users were inspected in depth and others sampled at random. All the care plans seen were detailed, current and were broken down into assessed needs with clear guidance for staff on how to meet these needs. The plans were also informed by relevant risk assessments; had up todate monthly summaries of progress made in meeting the identified needs and had been signed by the service user to evidence that they had been involved in making and monitoring the plans. The senior support worked showed the inspector work in progress in combining the care planning process with developing person centred plans (PCP’s). This had been completed at the time for two service users with work underway for the other six. For the two that Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 10 were completed there was a separate folder that contained: a record of the latest assessed needs for the person taken from the last review; the care plan, an individual support plan; a person centred plan; a communication passport; a heath action plan and the latest service user involvement questionnaire regarding the quality of support in the home. The inspector was particularly impressed with this work as it clearly showed a high degree of service user participation in the process and this was confirmed by independent discussion with service users. Service users spoken to confirmed that they were supported to make decisions for themselves. The majority can and do travel independently in the community. Where restrictions are placed on this, for example under restrictions imposed by mental health legislation, these are clearly recorded including discussions with those service users on the implications of these restrictions. As noted above under care planning above, the home undertakes a range of relevant risk assessments for service users and these were sampled at random. The home has a number of generic risks that are assessed for all service users on an individual basis. These include: issuing of front door keys, travelling independently in the community, window restrictors, use of hot water and smoking. These are supplemented by additional risk assessments for service users where other risk factors have been identified. There was evidence that the risk assessments are also reviewed regularly with the service user to ensure that they are up to date and that the guidance for staff on how to minimise these risks remains effective. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 17 Service users enjoy a range of appropriate activities including within the local community. Impressively they also continue to enjoy regular holidays to long haul destinations abroad that significantly contribute to enriching their life experiences. They also enjoy balanced, healthy and varied meals of their choice. EVIDENCE: Service users attend a range of relevant daytime occupation within the local community. This includes day services and attendance at local education facilities. One service user is a practicing Muslim and is supported in this including being supported by staff to attend their Mosque for worship. The service user spoken to independently indicated that this support was given in a sensitive and supportive way. Evidence was seen that staff were working with individual service users to develop their communication passport as referred to in the Individual Needs and Choices section of this report. Service users are supported to record in these their likes and dislikes as well as their aspirations for the future. These are considered essential by the home in developing individual person centred plans. The inspector was informed that the process of developing the communication passports allowed staff and service users to Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 12 explore options for service users to try out new experiences including identifying valued daytime activities for them to undertake. Evidence was seen that service users are able to access the varied local community resources including shops, pubs, restaurants, cinema and recreational facilities. The records for the latest service user to be admitted to the home showed a full activity programme. This included: playing pool, playing snooker, playing handball, playing football, going horse riding, attending a local leisure centre and various trips to local restaurants for meals. Service users continue to be supported to go on holidays abroad each year, often to exotic long haul destinations. In previous years service users have been supported to go on holiday to Malaysia, Croatia, Mexico, Thailand and Goa. The inspector was informed that active preparations were taking place for service users to go on holiday to Borneo for three weeks in April 2006 and service users spoken to were excited about this. The home had a four weekly menu with evidence that service users were involved in planning this at monthly service user meetings. The home can cater for different dietary requirements and cultural needs. Meals are prepared, cooked and eaten in the kitchens/ dining rooms at both houses. Service users are actively encouraged to be involved in the preparation and cooking of meals. The kitchens in both houses were inspected and were clean, tidy and satisfactorily equipped. The food was stored appropriately and matched the menu. Satisfactory records of fridge and freezer temperatures were seen. The inspector was pleased to see that the kitchen floor in one of the houses had been retiled as was required at the last inspection. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Service users are protected by robust polices and procedures regarding medication and its administration and are encouraged to take as much responsibility for administering their own medication as much as possible to assist promote their independence in this area. EVIDENCE: Medication and medication administration record (MAR) charts were inspected for two service users. These were both satisfactory and showed evidence that service users are encouraged to take as much control over the administration of their medication as possible. Evidence was seen that where appropriate identified service users are monitored controlling their own medication rather than have staff administer it directly. Evidence was seen from staff files sampled that staff are trained in the safe administration of medication. The senior support worker confirmed that after staff are first recruited they are trained in this area as a matter of priority and also confirmed that all staff also undertake regular refresher training in this area. The inspector also saw evidence that the senior support worker monitors the administration of medication process closely and took clear management action if this was not undertaken to his satisfaction. The inspector was pleased to see that MAR sheets supplied from the dispensing pharmacist did not include a record of medication that had been discontinued by the GP as had been required at the Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 14 last inspection. The inspector was also pleased to see that written guidelines for staff on collecting medication for service users had been proactively amended to assist with this process since the last inspection. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users and relatives are able to express their views, concerns and complaints and be confident that these will be taken seriously and appropriately dealt with by the home. EVIDENCE: The home has a robust complaints policy and procedure that was seen. Three concerns had been raised by service users since the last inspection and had been dealt with under the home’s complaints procedure. Evidence was seen that these had all been thoroughly investigated by the home within the required timescales with two being not substantiated and one being partly substantiated. The senior support worker indicated that thorough investigation of complaints and their resolution was a clear part of the home’s quality monitoring process. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 & 30 Service users live in a home that is comfortable, well decorated and well maintained. Service users also benefit from well-equipped bedrooms that they are supported to personalise to their taste. The home was clean and tidy throughout creating a pleasant environment for those that live and work at the home as well as for those that visit it. EVIDENCE: The home consists of two separate mid-terrace houses in a residential area close to the main Wood Green shopping centre with good public transport. All accommodation is for service users who are physically able and there are no facilities for service users with physical disabilities. Evidence was seen that the home had a planned maintenance and redecoration programme, one house was in the process of being redecorated at the time of the inspection. The inspector was pleased to see that a number of redecoration and maintenance items identified at the last inspection had been satisfactorily dealt with. The senior support worker stated that the home was considering removing an internal wall between the kitchen and dining room in each house to give a larger kitchen/ diner to improve those facilities for service users and staff. The inspector was independently invited by a service user from each house to visit their bedrooms. These were seen to be appropriately decorated, furnished and Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 17 personalised to the extent that the service user wished, one contained a range of items that promoted the football club that the service user supports. All service users spoken to indicated that they were happy with their bedrooms. Both houses were clean and tidy throughout with mess and disruption caused by the decorating work being undertaken being kept to a minimum. Laundry facilities in both houses were domestic in scale and were appropriate for the needs of the service users. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Service users are protected by the home’s recruitment procedures that are robustly implemented. Staff are offered a wide range of relevant training, including good quality induction training, to assist them in their own personal development and in meeting service users needs. EVIDENCE: The home had recruited three new staff since the last inspection and their staff files were inspected. All three files showed evidence that the home has and implements a robust recruitment procedure throughout the process. All three files contained: satisfactory enhance criminal records bureau (CRB) checks that included protection of vulnerable adults (POVA) checks; two written references that were verified where it was felt appropriate by a follow up telephone check; identification with a photograph; an employment history; a contract of employment and a health questionnaire. The three staff files inspected also showed substantial evidence that the home is also committed to staff training. A detailed induction checklist was seen on the three files with each element being signed by both the staff member and a manager. Evidence was also seen that these staff had undertaken a range of core skills training since being employed. This included: fire safety, food hygiene, safe use of medication, infection control, communication skills and first aid. All three staff had also undertaken non-violent crisis intervention training and the senior support worker stated that he was now an accredited Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 19 trainer for this subject. All three staff were booked onto a core values training course for the week following the inspection. One of these newly appointed staff was spoken to independently and indicated that he thought the training was useful, relevant and assisted in supporting the service users in their daily lives. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Service users are protected and supported by an effective and proactive system of management in the home. EVIDENCE: It was clear throughout the inspection process that the registered provider/ manager had delegated a significant amount of the day-to-day management responsibility for the home to the senior support worker. The senior support worker indicated that this had been fully negotiated and that he viewed this as being a constructive development to allow him to develop his own management skills. The senior support worker stated that the registered provider/ manager monitored his work and that he was very much supported by him. The senior support worker stated that he was in the process of finishing his Registered manager’s Award and that he anticipated that he would complete this by March 2006. The inspector was impressed by the overall knowledge about the home and the service users that the senior support worker was able to demonstrate. The inspector was shown evidence of decisive management action that had been taken regarding two separate staff Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 21 performance issues that had occurred since the last inspection. The senior support worker indicated that he was well supported by the registered provider/ manager throughout these two incidents. Staff and service users spoken to throughout this inspection were positive and complimentary about the management of the home. They also indicated that they appreciated the positive and optimistic ethos that this generated. Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 22 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 X ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X X X X X X Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Coleraine Road 30 & 37 DS0000010714.V279440.R01.S.doc Version 5.1 Page 24 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. 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