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Inspection on 21/11/06 for Edgeworth Crescent 55

Also see our care home review for Edgeworth Crescent 55 for more information

This inspection was carried out on 21st 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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a high standard of care and support to a group of service users with a range of complex needs. The home meets the service users cultural and religious needs and enables them to be part of the wider Jewish community. The home by working consistently and professionally with the service users in partnership with other care professionals is able to support the service users to make significant progress with their personal development. The manager and staff demonstrated a good knowledge of the service users and were able to recognise their individual needs and how to respond appropriately to them.The service users are supported to have their individual needs met by a comprehensive care planning system, which incorporates ongoing review meetings. The service users are supported to develop their independent living skills in the home and community, based on their individual needs. The service users are supported to access a range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The service users all feel able to express their views on the running of the home and their daily lives. A team of staff that are effectively managed support the service users. The staff have access to a comprehensive induction and an ongoing programme of training to enable them to perform their roles to a high standard. The manager and staff show a high level of enthusiasm and commitment to their work in the home. The home is very clean, comfortable and homely and the service users each have an attractive single bedroom. The service users are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures, comprehensive risk assessments, health and safety procedures and an effective complaints procedure.

What has improved since the last inspection?

What the care home could do better:

There are thirteen requirements and one recommendation made at this inspection. One requirement was made under the heading choice of home. This was to ensure all the service user assessments are available in their case notes. One recommendation was made under the heading individual needs and choices. This was to invite care managers to an annual care plan review. Two requirements were made under the heading of personal and healthcare support to ensure that all the service users have been supported to have an optical check and to remove staff names if they are no longer working in the home from the list of staff who can administer medication. Two requirements were made in the section concerns complaints and protection. The first was to ensure all the staff have been trained on the protection of vulnerable adults and how to appropriately support service users who have complex behaviours. The second was to review the process for recording service users personal monies to ensure they are appropriately protected. In the section on staffing three requirements were made. Firstly to ensure the staff recruitment process is completed to fill the vacancies in the staff team and to deploy staff effectively to ensure service users are supported throughout the day. Secondly to ensure staff have ID in their file and their contracts are signed. Staff also all need to receive training on mental health and epilepsy. Four requirements were made in the section called conduct and management of the home. Firstly the manager needs to complete the registration application process. Secondly a quality assurance action plan needs to be prepared for the home based on the outcome of the quality assurance exercise. Thirdly the fire extinguishers need to be serviced and a fire safety risk assessment needs to be prepared. All staff need to be trained on fire safety, moving and handling and food hygiene.

CARE HOME ADULTS 18-65 Edgeworth Crescent 55 Hendon London NW4 4HA Lead Inspector Jane Ray Key Unannounced Inspection 21st November 2006 09:45 Edgeworth Crescent 55 DS0000010426.V313350.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 Edgeworth Crescent 55 DS0000010426.V313350.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. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edgeworth Crescent 55 Address Hendon London NW4 4HA 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 8203 4707 020 8203 4707 edgeworth@norwood.org.uk www.norwood.org.uk Norwood Ravenswood Ltd T/A Norwood Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1), Physical disability (1) of places Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 6 adults of either gender with a learning disability (LD). Specific Service user with a Physical Disability One specific service user who is currently resident in the home and also has a physical disability can reside in this home. This condition will need to be reviewed when s/he vacates the home. Specific service user over 65 years One specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. 5th January 2006 3. Date of last inspection Brief Description of the Service: Edgeworth Crescent is a residential care home accommodating six younger adults with mild to moderate learning disabilities. The current service users also need support with their mental health. The home is owned and run by Norwood a Jewish Charity that provides a service to children, adults and their families. The homes stated objective is to provide safe and secure twenty-four hour care in a homely environment to adult males and females with learning disabilities. The house was built in the 1920s as a private dwelling and was eventually converted into residential care home and opened in 1995. The entrance leads into a large lounge there are two service users bedrooms both with en-suite facilities. In addition there is a laundry room, small reception room, bright lounge and a large bright kitchen/diner. On the first floor there are four bedrooms a large bathroom and a shower toilet room. The small open plan office has been designed and converted within the upstairs hallway and is accessed from two stairways, one of which leads directly into the office. The home has a secluded back garden, which is set on two levels. At the time of the inspection there were six service users living in the service. The current range of fees in the home is from £998 - £1266 a week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 21 November and was unannounced. The inspection lasted for six and a half hours and was the key annual inspection. The inspector was accompanied by a colleague from CSCI, who was attending the inspection as part of his training programme. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to meet, speak to and observe the support given to five of the current six service users. The inspector was also able to spend time talking to three members of care staff who were working in the home. The manager attended part of the inspection. The inspector did a tour of the premises and looked at service user bedrooms where the service user gave their permission for this to take place. She also looked at a range of records including service users records, staff files and health and safety documentation. The inspector had also received a completed pre-inspection form from the home and feedback forms from six service users, two health care professionals and two relatives. The inspector would like to thank the service users and staff for their assistance with the inspection process. What the service does well: The home provides a high standard of care and support to a group of service users with a range of complex needs. The home meets the service users cultural and religious needs and enables them to be part of the wider Jewish community. The home by working consistently and professionally with the service users in partnership with other care professionals is able to support the service users to make significant progress with their personal development. The manager and staff demonstrated a good knowledge of the service users and were able to recognise their individual needs and how to respond appropriately to them. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 6 The service users are supported to have their individual needs met by a comprehensive care planning system, which incorporates ongoing review meetings. The service users are supported to develop their independent living skills in the home and community, based on their individual needs. The service users are supported to access a range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The service users all feel able to express their views on the running of the home and their daily lives. A team of staff that are effectively managed support the service users. The staff have access to a comprehensive induction and an ongoing programme of training to enable them to perform their roles to a high standard. The manager and staff show a high level of enthusiasm and commitment to their work in the home. The home is very clean, comfortable and homely and the service users each have an attractive single bedroom. The service users are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures, comprehensive risk assessments, health and safety procedures and an effective complaints procedure. What has improved since the last inspection? At the last key inspection on the 5 January 2006 thirteen requirements were made. With the exception of a small amount of building work all these requirements have now been met as follows: • • • • • Service users have now signed their care plans and staff were knowledgeable about the contents of the care plans Service users are being supported to attend specialist healthcare appointments Prescribed creams and powders are being signed for on the medication administration record The names and signatures of staff trained to administer medication in the home is recorded at the front of the medication file Building work is completed including the replacement of the kitchen, replacement of the first floor bathroom, refurbishment of the first floor Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 7 • • • • shower room and replacement of the lounge curtains. In addition most of the home has been redecorated. The service user files have been reorganised and are easy to follow The hot water temperature in the house has been regulated The COHSS cupboard is now locked The manager has taken steps to minimise the risk of the front door being left open and throughout the inspection the door was observed to be shut What they could do better: There are thirteen requirements and one recommendation made at this inspection. One requirement was made under the heading choice of home. This was to ensure all the service user assessments are available in their case notes. One recommendation was made under the heading individual needs and choices. This was to invite care managers to an annual care plan review. Two requirements were made under the heading of personal and healthcare support to ensure that all the service users have been supported to have an optical check and to remove staff names if they are no longer working in the home from the list of staff who can administer medication. Two requirements were made in the section concerns complaints and protection. The first was to ensure all the staff have been trained on the protection of vulnerable adults and how to appropriately support service users who have complex behaviours. The second was to review the process for recording service users personal monies to ensure they are appropriately protected. In the section on staffing three requirements were made. Firstly to ensure the staff recruitment process is completed to fill the vacancies in the staff team and to deploy staff effectively to ensure service users are supported throughout the day. Secondly to ensure staff have ID in their file and their contracts are signed. Staff also all need to receive training on mental health and epilepsy. Four requirements were made in the section called conduct and management of the home. Firstly the manager needs to complete the registration application process. Secondly a quality assurance action plan needs to be prepared for the home based on the outcome of the quality assurance exercise. Thirdly the fire extinguishers need to be serviced and a fire safety risk assessment needs to be prepared. All staff need to be trained on fire safety, moving and handling and food hygiene. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 8 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. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Service users have been supported to have comprehensive assessments but these need to be available in all the service users records. Service users can be assured their individual needs will be met by the home. EVIDENCE: The inspector looked at four service user case notes. They have comprehensive assessments prepared by the home that look at all aspects of their physical, social, cultural and emotional needs. These assessments are completed to a high standard and reflect the detailed knowledge the staff have of the service users individual needs. This provides valuable information for staff to enable a holistic view of each individual to be understood. One service user did not have an assessment available in her case notes at the time of the inspection. The inspector observed that the staff were supporting the service users in an appropriate manner that reflected their knowledge and understanding of their individual needs. The service users were also observed to be comfortable and relaxed within their home environment. Two of the service users told the inspector how they were very happy in the home and felt well supported by the staff team. Edgeworth Crescent 55 DS0000010426.V313350.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is excellent. This judgement has been made from evidence gathered during the visit to this service. Service users are each supported to have comprehensive individual care plans and risk assessments and are working towards clearly defined goals agreed in partnership with families and other care professionals. Service users are supported to make decisions about their daily lives within the home and service user meetings take place regularly. EVIDENCE: Four service user case notes were inspected. Each service user has detailed individual care plans. These reflect the decisions made at each service users review meeting where they are supported to make decisions about their personal goals. These meetings take place with the care manager approximately once a year and there is also a review meeting arranged by the home on a six monthly basis. These review meetings were clearly recorded and demonstrated multi-disciplinary working. It was noted that one service user whose placing authority is Barnet had not had a review meeting with her care manager for over a year. It is recommended that the care manager is invited to attend the annual review meeting. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 12 The care plan goals are clear and easy to understand and are monitored on a monthly basis. These goals focus on supporting the service users to gain greater independence and to look a how their lives can be further enhanced by improved activities or by addressing healthcare or emotional issues. The four service users all had a named key worker and they are involved in maintaining the care planning documentation. All the service users spoken to were able to tell the inspector the name of their key worker and what activities they did together. In addition two staff who were interviewed were able to fully describe their role as a key worker and this role was being performed in a very comprehensive manner. The four service users had all signed their care plans and one service user told the inspector how her key worker had discussed her care plan with her as part of this process. The four service users whose case notes were inspected all have complex emotional and behavioural needs. Each service user has guidelines as part of their assessment or as a separate document describing these behaviours and this enables the staff to identify when the service user is distressed and what action they should take in response to this situation. These guidelines were clear and could be followed by the staff team. One member of staff when asked could clearly explain how they support a service user when he is distressed. Some of the service users have restrictions in place, for example some service users need to have support to manage their personal money or need staff support when out in the community. The reasons for these restrictions are recorded in their care plan and risk assessment. Each service user has a record of the individual arrangements in place to support them to manage their personal finances including an individual risk assessment. The four service user case notes inspected all included comprehensive individual risk assessments covering all areas of potential risk and this identified what action the home would take in response to the identified risks whilst at the same time promoting each service users independence. These covered a number of areas including accessing the community, safety during food preparation and mealtimes and bathing for example. Throughout the inspection the service uses were observed being consulted about decisions concerning their daily lives. This included being asked what they wanted to drink and when they felt ready to go out. The record of the service user meetings was inspected. These took place on a regular weekly basis and discussed activities, domestic chores, holidays and things that were happening in the home. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 13 Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered during the visit to this service. The service users are supported to have full and active lifestyles. They also enjoy contact with their relatives and friends. The service users are offered a wholesome and healthy diet. EVIDENCE: The service users, manager and staff explained that the service users access a range of activities based on their individual needs and interests. This includes going to college, attending a number of sessions at resource centres and supported employment. One service user explained how she enjoys her administration work with another voluntary organisation. Service users also explained how they enjoyed music, art and multi-sensory sessions at a number of community resources. The manager explained that some service users are employing a tutor who comes to the home to help them learn another language. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 15 The service users are supported to enjoy a number of leisure activities including going to the theatre, bowling, cinema and eating out. Some of these activities are organised by a Norwood social club called Links. On the day of the inspection the service users were observed going out shopping, having lunch out and attending various structured sessions. The inspector also saw that service users are active within the home and are being supported to develop their independent living skills. The service users were able to tell the inspector how they enjoy practising their religion. This includes a traditional meal on a Friday night and they were looking forward to a Chanukah party that was arranged in December. All the service users were able to tell the inspector how they had enjoyed a summer break. These breaks had either taken place individually or as part of a small group according to the individual wishes of the service users. Holidays that had taken place included trips to Bournemouth and Nottingham. The manager explained that all of the service users have contact with their families or friends. They are made welcome in the home or service users are supported to go to their family homes. The service users were able to tell the inspector about how they enjoy seeing their relatives and also have friends from other Norwood homes. It was observed that there was a friendly atmosphere in the home with the staff chatting to the service users. The service users were observed to be very relaxed with the staff. It was observed that service users were being supported to follow their own routine with one service user choosing to have a later breakfast at the time of the inspection. The menu for the week was inspected and this offered a healthy and varied diet. The manager explained that the service users each choose a meal at the weekly residents meeting and then are supported by staff to prepare the meal. They all follow a healthy eating plan. The service users spoken to also told the inspector about how they choose and prepare the meals. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is excellent. This judgement has been made from evidence gathered during the visit to this service. Service users are supported to receive personal care according to their individual needs and wishes. Service users are supported to access healthcare services based on their requirements although some do need optical checks. Service users have their safety maintained by appropriate medication administration procedures. EVIDENCE: It was observed during the inspection that the service users were given support with their personal care based on their individual needs. Some just need prompting whilst others need individual support. The service users were all very well dressed and groomed. Two service users were able to tell the inspector how they go to a local hairdressers to have their hair cut. The healthcare records were inspected for four service users. They had all been supported to access the GP and dentist, but two of the four service users had no record of going to the optician in the last two years. They all see the consultant psychiatrist on a regular basis. In addition service users attend outpatient appointments for their specialist healthcare needs and it is also positive to note that a number of other therapy services including psychology and physiotherapy have been accessed as required for specialist advice. All Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 17 healthcare appointments are appropriately recorded and include the outcomes of the appointments. The inspector also noted that one of the service users has had very complex health care needs since the previous inspection. The inspector saw that this service users records had been maintained to a very high standard so that all the healthcare input was evident and follow up action being monitored. Service users are also supported to have their weight checked on a monthly basis. The medication systems in the home were inspected. The home uses the Boots pharmacy blister pack system. The medication was appropriately stored and the temperature of the medication cupboard was recorded daily. The medication administration records were completed correctly for all medication including creams. The medication entering and leaving the home is recorded appropriately on the medication administration record. Some of the service users have PRN medication linked to their emotional needs and there are guidelines in place for them explaining when the medication should be administered. The home has a list of staff who can administer medication with their signatures and it was noted that this includes staff who have left and their details need to be crossed out. The staff training records were inspected and all the staff who administer medication had an appropriate training certificate to confirm medication training had taken place. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. Service users can be confident that any complaints they may wish to make will be appropriately addressed. Some staff still need to be trained on the protection of vulnerable adults and service users need to be protected by ensuring there is an audit trail for their personal finances. EVIDENCE: The manager explained that the home has received no complaints since the previous inspection. The inspector looked at the complaints procedure and this is a comprehensive document. The staff training records were inspected for four members of the staff team. These indicated that one of the staff had not received training on the protection of vulnerable adults. The staff member also confirmed that he had not yet attended this training. Norwood has a comprehensive adult protection procedure and the home also has Barnet’s procedure available. The staff training records also showed that two of the four staff whose records were inspected had not had training on how to work positively with service users who have complex challenging behaviours. The personal finances were inspected for two service users. Both service users keep their building society books for safe-keeping in the safe in the office and are supported by staff to withdraw cash from their accounts. Both service users also leave cash in the safe in the office. One service user when she withdrew cash from the building society had a record of this cash in her client Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 19 money record in the home. She then signed when she took cash from her money tin in the home. This allowed the home to have evidence of an audit trail for her money. The other service user did not have a record of her withdrawn cash from her building society account in her client money record. This meant that no audit trail was available for her money. The inspector requires this system to be reviewed so that the service users finances can be safeguarded. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made from evidence gathered during the visit to this service. Since improvements have taken the service users now live in a homely, comfortable and safe environment that is well maintained. EVIDENCE: The inspector did a tour of the home and looked at some of the bedrooms where the service users gave their permission. The home was clean and tidy throughout. Each service users bedroom that was seen was well furnished and was homely and personalized. The communal space consists of a large lounge, kitchen with a dining area and small TV room. These were also well furnished and comfortable. There are adequate bathing facilities on each floor. The home has a laundry on the ground floor. All the equipment in the home was observed to be in good working order. There was some ongoing work, taking place in the home including the repair of the boiler that was making a loud banging noise, the repair of the patio and the completion of the upstairs shower room. It was observed that the upstairs shower room door has been damaged and was in the process of being replaced. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 21 Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. The service users are supported by a capable staff team, but staff vacancies need to be filled and some training completed to ensure high standards are maintained. EVIDENCE: The inspector looked at the staff rota. The staff team consists of a manager, deputy manager, 3 senior carers and a team of carers. The staff turnover is fairly low, with two staff leaving in the last six months and one member of staff going on maternity leave. There are however a number of staff vacancies in the home and these are currently filled using bank or occasional agency staff. These vacancies need to be filled to provide consistency of care and the manager explained that a recruitment process is underway. During the day there are between two and four staff working in the service according to the activities planned and 1:1 staff hours available for the service users. At night there is one waking member of staff. One service user has experienced a significant change in his needs and the manager explained that funding for additional staff hours have just been approved. One member of staff said that it can be very hard for two staff to manage in the evenings with personal care and supper taking place. The manager will need to consider carefully how the additional staff hours will be deployed to meet the needs of the service users. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 23 The manager explained that out of the current ten members of staff, three have completed the NVQ level 2,3 or 4 in care and four staff are studying for and NVQ in care. The recruitment checks were inspected for four staff and these were partly in place including the application form, CRB disclosure and two references. Two staff did not have ID or a work permit where needed in their staff file. All the staff had a copy of their contract of employment in their record but one member of staff had not signed their contract. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. The induction records were inspected for four staff and were in place. One recently appointed member of staff was able to describe her induction and how she shadowed an experienced member of staff until she felt confident in her role. The staff training records were inspected for four staff members. It was noted that only one of the four staff had a record of receiving training on mental health, which is a care need for all the service users. One member of staff who had transferred from another home had no record of receiving epilepsy training. The staff supervision records were inspected for four staff. All the staff were receiving regular individual supervision on a two monthly basis. The home uses a comprehensive supervision format and these were appropriately completed. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. The service users are benefiting from living in a well-managed service where the focus is on providing a high standard of care and support. Some health and safety measures need to take place to protect the service users. EVIDENCE: The home has a manager who is providing a high standard of leadership to the service. She needs to complete the registration process. The manager explained that the organisation has undertaken a quality assurance exercise that has included consulting with service users and relatives. She is attending a meeting to receive feedback on the outcomes of this exercise. The manager needs to ensure that the process of the quality assurance exercise is known in the service and that there is an action plan to address issues raised that affect the quality of the service. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 25 The home has appropriately reported any serious incidents concerning the service users to the CSCI and completes regular provider monthly visits. Fire safety measures are partly in place. The fire safety records were inspected and weekly fire alarm checks and monthly fire drills are recorded. On the day of the inspection the fire doors in the home were closed. The fire alarm had received its annual service but there were no records of the extinguishers being serviced since September 2005. The home has an evacuation plan and fire safety risk assessment. The certificates were in place to confirm the electrical installations, portable electrical appliances, gas and water systems had been serviced. The water temperature was checked in the three bathrooms and was satisfactory. The home is maintaining weekly water temperature checks. The current insurance certificate was displayed and was satisfactory. The staff training records for four staff were inspected and three had no record of receiving training on moving and handling or fire safety. One member of staff also had no record of food hygiene training. All the staff had received first aid training. The records in the home were observed to be well organised and maintained. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 4 4 x 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 1 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 4 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 2 x 3 1 x Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 YA2 YA19 Regulation 14(2) 13(1)(b) Requirement The registered person must ensure each service user has a current assessment available. The registered person must ensure all the service users have been supported to have a current optical check. The registered person must ensure that staff who no longer work in the service have their names crossed off the list of people who are permitted to administer medication. The registered person must ensure that all staff have received training on the protection of vulnerable adults and how to positively support service users who have complex or challenging behaviours. The registered person must review the procedure for recording service users personal monies to ensure that an audit trail is available and their monies are protected. The registered person must ensure staff vacancies are filled and that staff are deployed to ensure the needs of the service DS0000010426.V313350.R01.S.doc Timescale for action 31/12/06 15/01/07 3. YA20 13(2) 15/12/06 4. YA23 13(6)(7) 31/03/07 5. YA23 12(1) 15/12/06 6. YA33 18(1) 31/12/06 Edgeworth Crescent 55 Version 5.2 Page 28 7. YA34 8. YA34 9. YA35 10. 11. YA37 YA39 12. 13. YA42 YA42 users are met throughout the day and evening. 19(1)-(5) The registered person must ensure each member of staff has a record of their ID in their staff file. 17(2) The registered person must ensure all staff have a signed contract of employment in their staff record. 18(1)(c) The registered person must ensure all staff have received training on mental health and epilepsy to enable them to meet the needs of the service users. 8(1) The registered person must ensure the manager submits the registration application. 24(1)-(3) The registered person must ensure that the results of the quality assurance exercise are available in the service and an action plan prepared for the home to address issues relating to the service. 23(4) The registered person must ensure the fire extinguishers have been serviced. 13(3)(4)(5) The registered person must ensure all the staff have received training on fire safety, moving and handling and food hygiene. 31/12/06 31/12/06 31/03/07 31/12/06 31/01/07 15/12/06 31/03/07 Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 29 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 YA6 Good Practice Recommendations The registered person should ensure that each service users care manager is invited to a care plan review meeting on an annual basis. Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 30 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 Edgeworth Crescent 55 DS0000010426.V313350.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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