Inspection on 14/09/07 for Cranbrook Road (477-481)

This inspection was carried out on 14th September 2007.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cranbrook Road (477-481) 08/01/07

Cranbrook Road (477-481) 03/04/06

Cranbrook Road (477-481) 19/10/05

Cranbrook Road (477-481) 07/04/05

Cranbrook Road (477-481) 19/07/04

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 Cranbrook Road (477-481) 477-481 Cranbrook Road Ilford Essex IG2 6ER Lead Inspector Ms Gwen Lording Unannounced Inspection 14 September - 5 October 2007 09:45 th th Cranbrook Road (477-481) DS0000052799.V345422.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 Cranbrook Road (477-481) DS0000052799.V345422.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. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cranbrook Road (477-481) Address 477-481 Cranbrook Road Ilford Essex IG2 6ER 020 554 2057 0208 518 6091 info@saharahomes.co.uk 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) Sahara Homes Ltd Manager not currently registered Care Home 19 Category(ies) of Learning disability (19) registration, with number of places Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th January 2007 Brief Description of the Service: 477 Cranbrook Road is a care home providing accommodation and support for service users with a learning disability/ physical disability and associated challenging behaviours. The registered providers are Sahara Homes Limited. The home is registered to accommodate 19 service users in two separate units of 10 and 9. House One is wheelchair accessible and has a passenger lift. House Two is more suitable for service users who are independently mobile. The home is situated in a busy residential area of Gants Hill in the London Borough of Redbridge. The area is well served by public transport and there are many easily accessible facilities and amenities within the local area. The home has its own transport. There is a large rear garden, which is wheelchair accessible. The home aims to integrate the service users into community life and supports them to access and participate in mainstream as well as specialist resources in the community in which they live, within their individual capabilities. On the day of the inspection the range of fees for the home was between £500.00 and £2,000.00 per week. A copy of the Statement of Purpose and service user guide is made available to both the residents and their family or representative. A copy of both these documents and the most recent inspection report are available in both House’s 1 and 2. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two days. The inspection was undertaken by the lead inspector, Gwen Lording. Discussion took place with the manager, deputy manager and several members of care staff. On the second day the inspector spoke to residents where possible and asked their views on the service and their experience of living in the home. Due to the level of disability of some residents it was not possible to fully obtain their views. However, the inspector was able to communicate with some residents with the assistance of staff. Care staff were asked about the care that residents receive, and were also observed carrying out their duties. A tour of both houses, including the kitchens was undertaken and all areas were clean with no offensive odours present throughout. A random sample of residents’ files were case tracked, together with the examination of other staff and home records. This included medication administration; staff rotas; training schedules; maintenance records; menus; complaints; fire safety; accident/ incident records and staff recruitment procedures and files. Information was also taken from an Annual Quality Assurance Assessment (AQAA), which was completed by the manager. This is a self-assessment process, which all providers are required to complete once a year. Additional information relevant to this inspection was also obtained from monthly Regulation 26 monitoring reports and Regulation 37, notification of events. As part of the inspection process the views of several community health and social care professionals who provide a service to the home were sought and are commented on in this report. People living in the home where possible, and staff were asked how they wished to be referred to. The majority expressed a wish for the term resident to be used, as it is their home. This is reflected accordingly in the report. The inspector would like to thank the residents and staff for their input and assistance during the inspection. What the service does well: As part of the inspection, contact was made by phone with community health and social care professionals who visit or provide a service to the home. They commented very positively on their involvement with the home and expressed no concerns about the care being provided; effective communication was highlighted as a particular strength of all staff. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 6 Discussion with those residents were possible, indicated that they were happy with the care and support they were receiving. “I like living here, I talk to my key worker and she helps me with lots of things”. It was evident that residents have confidence in the staff that care for them, and staff demonstrated a good understanding of the particular needs of all residents. Staff were seen to have the skills to communicate effectively with all residents. During the inspection staff were observed providing residents with assistance and support and were respectful of their right to make decisions. The service does not employ any domestic staff and care staff have responsibility for the cleaning. All areas of both houses were clean, tidy and free from odour throughout. What has improved since the last inspection? What they could do better: It is strongly recommended that consideration be given to allowing residents to have more involvement and influence in shopping for the home, and take into account individual likes/ dislikes. The improvements to House 2 have gone some way to achieving a more homely environment for residents. However, the home has now been open for a number of years and much of the décor in both houses is now being to look ‘tired’ and needs upgrading. The registered providers must ensure that there is an ongoing programme of decoration for all areas of both houses. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2, 3 & 4 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The assessments completed by the home and the information and reports received from health and social care professionals means that staff have the information to enable them to determine whether or not the home can meet a prospective residents needs. EVIDENCE: There are currently thirteen residents accommodated in the home, which includes a number of residents on respite placements. Individual records are kept for each resident and a number of files were examined, including the records for the most recently admitted resident. All files inspected have assessment information recorded and the information had been used to develop written care plans. All residents admitted for a trial placement have a ‘settling in’ period. This is followed by a multi-disciplinary review to decide on whether the placement can be made permanent. The manager determines if the home can fully meet the prospective residents needs and consideration is given to the existing group of residents and the compatibility of the new resident. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 10 The manager was provided with a copy of the Commission’s ‘Policy and Guidance on Provision of Fees Information by Care Home’s’. This sets out what information care home providers need to include in the Service User Guide regarding fees and terms and conditions, and is in a format that is easy to understand. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. Residents health, personal and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily understand and meet individual residents needs. The home maximises independence wherever possible and staff provide service users with information, assistance and support to make decisions about their own lives. EVIDENCE: Individual files were available for each resident and the records of six residents were case tracked. There has been a significant improvement in the standard of care plans and generally follow the principles of person centred care. The care plan is presented in a part pictorial format and staff use a variety of methods to assist individual residents in the development of their care plan Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 12 and review process. It identifies needs, likes, dislikes, support; and considers all areas of the residents life including health, personal and social care needs. It was clear that care plans had been drawn up with the involvement of the individual, wherever possible. Each resident has a separate health care plan and a daily communication diary. A key worker system allows staff to work on a one to one basis and contribute to the care plan for the individual. The care plan can easily be used and understood by people who are not familiar with the individual to ensure continuity of care. There was evidence that care plans were being reviewed/ evaluated at least monthly and updated to reflect changing needs. Risk assessments were in place for each service user and were being regularly reviewed. They identified risks for residents and detailed actions to keep any such identified risks to a minimum. This included risks associated with physical/ verbal aggression. Information is displayed on the residents’ notice board in the main corridor about how to access local advocacy services and several residents have named advocates. There is a strong focus on maintaining and promoting independence whenever possible, and individual staff were observed providing residents with information, assistance and support, and were respectful of the individuals right to make decisions. The file of one resident evidenced a letter to their social worker that staff had supported them to write and send. Cranbrook Road (477-481) DS0000052799.V345422.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): Standards 11, 12, 13, 14, 15, 16 & 17 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. Residents are actively encouraged and supported to be involved in social and leisure activities, appropriate to the individual. They are supported to exercise their rights, which are respected and promoted by staff and enables individuals to participate in the community in which they live. EVIDENCE: Each resident has a planned activity programme, which takes account of the individual’s preferences, interests, experiences, age and capabilities related to their disability. Residents are individually and collectively involved in determining the type of activities they wish to participate in, when and with whom they choose. Resident meetings are held monthly and from viewing the minutes it was apparent that activities and other house matters are discussed. There is a wide range of leisure/social activities for residents to engage in both in the home and the community. Several residents attend specialist day Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 14 centres and other residents have programmes of activities being managed in the home by staff. All residents are supported to participate in leisure activities in the community, both specialist and mainstream. Residents are supported to exercise their choice in relation to their particular religious observance. For example, one resident’s care plans states: ‘Bible to be kept in bedroom. Other residents are supported to attend their chosen places of worship for example, church and temple. Where appropriate residents are involved in taking some domestic responsibility for their own rooms and personal laundry. One resident said: “I try and keep my room tidy and the staff help me”. During both days of the inspection, those residents who were able were observed accessing all areas of the home independently. All staff are very aware that Cranbrook is the home of the residents, they respect this and try to make this as pleasant as possible. The home has its own transport, which is used for shopping trips, outings and escorting to day centres. Some residents make use of public transport and are well orientated in the community. One resident is able to mobilise independently in the community by use of his wheelchair. The home does not employ a cook and care staff shop, prepare, and cook all meals, with the involvement and a limited degree of support from individual residents. The staff are well aware of what each person likes to eat and those residents who have special dietary needs, such as diabetic diets. Religious or cultural dietary needs are also known and catered for and this is recorded in care plans, for example Halal diet. One the day of the inspection there were more than adequate quantities of food available, including fresh fruit/ vegetables, meat and fish. Many of the residents are able to help themselves to drinks and snacks whenever they wish. Currently the proprietor of the home arranges for the purchase of food to the home. However, two residents commented on the quality of some food items purchased, including sandwich fillings, yoghurts, sliced bread and cornish pasties; “more pastry than filling”. The inspector fed these comments back to the manager, who will in turn discuss this with the proprietor. Consideration should be given to allowing residents to have more involvement and influence in shopping for the home, and take into account individual likes/ dislikes. Relatives and friends are encouraged and welcomed to be involved in special events in the home, with individual residents agreement. All residents have a birthday celebration to which family and friends are invited. A thank you card from a relative on one of the notice boards read:”Thank you for the lovely party you put on. We all had a good time and the food and cake were great “. Two residents go home regularly to their family home for weekends. Cranbrook Road (477-481) DS0000052799.V345422.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): Standards 18, 19 & 20 People using the service experience good quality outcomes in this area. This judgement has been made using all available evidence including a visit to this service. Residents receive personal support in the way they prefer and their physical and emotional care needs are closely monitored to ensure that such needs are recognised and met. There are clear medication policies and procedures for staff to follow, so as to ensure that residents are safeguarded with regard to their medication. EVIDENCE: Three of the residents spoken to confirmed that they were happy with the support they receive around their personal care needs. Residents have a choice in relation to same gender care preferences when receiving personal care, and their care plans set out how their personal support is to be provided. All of the care plans examined clearly recorded referrals to specialist health care professionals for example, physiotherapist, psychologist, diabetic nurse specialist and community learning disability service; and that appointments Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 16 were being kept. Records also indicated that residents attend routine health appointments including GP, dentist and chiropodist. Staff are very observant and alert to changes in individuals behaviour and mood and understand how they should respond and the action required. Care plans detail specific behavioural interventions, particularly in relation to challenging behaviour. There are policies and procedures for the handling and recording of medication. Medication is stored in a locked medicine cupboard in the staff office and is appropriate to ensure the safekeeping of medicines in the home. An audit was undertaken of the management of medicines in the home, and Medication Administration Record (MAR) charts were examined. One resident is able to draw up and administer their own insulin with the support of staff however, there was no up to date risk assessment in place. This was highlighted with the manager who undertook a risk assessment at the time of the visit. Such risk assessments must be reviewed regularly. Discussion with staff and the review of medication records show that staff are following the policies and procedures, so as to ensure that residents are safeguarded with regard to their medication. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The manager and staff make every effort to sort out any problems and concerns. Residents and their relatives/ representatives can be confident that their complaints and concerns will be listened to and acted upon. All staff working in the home have received training in safeguarding adults to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a written complaints policy and procedure, which is also produced in a part pictorial format that is more easily accessible to this resident group. Staff spoken to were aware of the complaints procedure and how to deal with complaints or concerns made to them. The complaints log was inspected and indicated complaints, concerns and issues of dissatisfaction received, details of investigation, action taken to resolve and the outcome for the complainant. No complaints have been received by the Commission since the last inspection. All staff working in the home have received training in safeguarding adults and this is included in induction training for all new staff. This was evidenced on individual staff files and the training schedule. Those staff spoken to were conversant with the action to be taken if they has any concerns about the safety and welfare of residents or if they witnessed any suspected abuse. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 18 There is a policy and procedure in place and known by staff for the management of physical or verbal aggression by a resident. Training around dealing with physical and verbal aggression is undertaken by staff and all staff are trained in the use of a control and restraint technique ‘Non Violent Crisis Intervention’. Where incidents had required the use of physical restraint there were well-documented and clear records available. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The atmosphere in the home is generally very welcoming and the furnishings are of a good standard. Some improvements have been made since the last inspection to House 2 so that the living environment is more appropriate for the particular lifestyle and needs of the residents living there. EVIDENCE: Both houses were toured, accompanied by the manager on the first day of the inspection, and all areas were visited again on the second day. All of the bedrooms are single, have en suite facilities and are furnished and decorated to suit individual’s preferences and particular needs. All bedrooms seen were reflective of the individual’s interests, hobbies and lifestyle. Each house has a large lounge/ dining room, kitchen and utility room. The service does not employ any domestic staff and care staff have responsibility for the cleaning. All areas of both houses were clean, tidy and free from odour throughout. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 20 The furnishings and fittings in both houses are of a good standard and some improvements have been made since the last inspection. This includes: • The installation of a new lift in House 1 and carpets replaced in some communal areas. • The lounge in House 2 has been re-decorated and furniture replaced. • Re-decoration of several resident’s bedrooms. The improvements to House 2 have gone some way to achieving a more homely environment for residents. However, the home has now been open for a number of years and much of the décor in both houses is now being to look ‘tired’ and needs upgrading. The registered providers must ensure that there is an ongoing programme of decoration for all areas of both houses. Since the last inspection there been a significant increase in the number of residents accommodated. This means that both houses are now able to operate as two separate units under the management of one registered manager. Whilst activities and meals take place in each house, residents are free to access the communal areas of both houses. The manager has received information and is fully aware of the recent legislation regarding smoking in care homes, which came into effect on the 1st July 2007. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 & 35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. Residents benefit from a committed staff team who have the skills and training to meet their needs. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Staff rotas were inspected and staffing levels, gender and skill mix of staff was sufficient to meet the assessed care needs of residents. The home has a relatively stable workforce. There is no use of agency staff and any gaps in the rota to cover shortfalls such as sickness and annual leave are covered by an internal pool of bank staff. At the last inspection the home’s recruitment procedures were not being consistently followed for all staff. The files of the two most recently employed staff since the last inspection were inspected and these were found to be in Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 22 good order with necessary references, Criminal Records Bureau (CRB) disclosures, and application forms duly completed. There was evidence to show that the organisation is now operating a robust recruitment and selection procedure in accordance with the requirements of legislation, equal opportunities and anti-discriminatory practice, which ensures the protection of residents. Sahara Homes Limited as an organisation, employs a workforce from diverse cultures and backgrounds. It was apparent at the time of the inspection that the composition of the staff team was reflective of the culture, religion and gender of people living in the home. In discussion with the manager and staff they were able to demonstrate an awareness of the importance of understanding and appropriately meeting the needs of all residents, wherever possible around equality and diversity issues. Information included in the completed AQAA has identified the need for future training regarding equality and diversity issues and this will be accessed by all staff over the next year. This will ensure that the spiritual, cultural, sexual, and any other diverse need of residents’ at the home is met through meaningful ‘person centred ‘ care. A discussion took place with the manager around the recently introduced Mental Capacity Act 2005, and the impact it will have upon the delivery of care to vulnerable people. Five key staff have been identified to undertake this training. It is essential that all staff working in the home receive adequate and appropriate training in this important area. The manager stated that approximately 80 of care staff are qualified to National Vocational Qualification (NVQ) level 2 or above. Six of these staff are qualified to NVQ level 3, and four staff are currently working towards NVQ2. Staff training records showed that staff have received training in essential areas such as first aid, health and safety, manual handling and food hygiene. Other training undertaken by care staff includes diabetes awareness, management of medicines and use of hoists. Training around dealing with physical and verbal aggression is undertaken by staff and all staff are trained in the use of a control and restraint technique ‘Non Violent Crisis Intervention’. One of the deputy managers is an accredited trainer and undertakes refresher training at the required intervals. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 38, 39, 41 & 42 People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. The home is being efficiently managed, residents interests are safeguarded and they benefit as the home is run in their best interests. Monitoring visits are undertaken regularly by the responsible individual to monitor and report on the quality of the service being provided in the home. EVIDENCE: The current manager has now been in post since November 2006 and is now registered as the manager with the Commission. Significant improvement was noted in respect of the management of the service since the last inspection. Effective systems have been introduced to monitor practice and compliance with record keeping, adherence to policy and procedure, and management of Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 24 medicines. It was evident that the home is operated for the benefit of residents, and every effort is made to retain the independence of those people living in the home and for them to exercise choice and control over their lives. Ms Warren is very resident focused and has worked continuously to improve the service and provide an increased quality of life for residents, with the support of the deputy managers and core staff team. Staff spoke positively about her leadership and support. The manager is scheduled to commence her NVQ level 4 – Management, this month. The home benefits from the quality assurance procedures of the registered organisation, Sahara Homes Limited. A representative of the registered organisation undertakes monthly Regulation 26 monitoring visits to monitor and report on the quality of the service being provided in the home. A copy of the report is sent to the Commission. Currently the manager does not act as an appointed agent for any resident. Residents financial affairs are managed by their relatives/ representatives. The home has responsibility for the personal allowances of several residents and secure facilities are provided for their safekeeping. A written record is maintained of all transactions however; the manager must ensure that all entries are signed by two members of staff to provide safeguards for both residents and staff. A wide range of records were looked at including fire safety; emergency lighting; accident/ incident records and portable appliance testing. A fire risk assessment was completed in December 2006. These were found to be in good order, up to date and accurate. Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 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 2 X 3 3 3 X 2 3 X Cranbrook Road (477-481) DS0000052799.V345422.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 Requirement The registered persons must ensure that risk assessments are reviewed regularly for those residents who have responsibility for their own medicines. The registered providers must ensure that there is an ongoing programme of decoration for all areas of both houses. The registered providers must ensure that all entries made in respect of residents financial transactions are signed by two members of staff. This will provide safeguards for both residents and staff. Timescale for action 31/10/07 2. YA24 23 31/12/07 3. YA41 16 & 17 Schedule 4 05/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations The registered providers must ensure that all entries made in respect of residents financial transactions are signed by two members of staff. This will provide safeguards for both DS0000052799.V345422.R01.S.doc Version 5.2 Page 27 Cranbrook Road (477-481) residents and staff. Cranbrook Road (477-481) DS0000052799.V345422.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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