Inspection on 05/06/07 for Edgeworth Crescent 55

This inspection was carried out on 5th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edgeworth Crescent 55 21/11/06

Edgeworth Crescent 55 05/01/06

Edgeworth Crescent 55 10/02/05

Edgeworth Crescent 55 08/07/04

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 Edgeworth Crescent 55 Hendon London NW4 4HA Lead Inspector Peter Illes Key Unannounced Inspection 5th & 8th June 2007 09:00 Edgeworth Crescent 55 DS0000010426.V336953.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.V336953.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.V336953.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 bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood ** Post Vacant *** 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.V336953.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. 21st November 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. Some of the people living at the home 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 a residential care home and opened in 1995. The entrance hall leads to a large lounge and there is one residents’ bedroom with en-suite facilities on the ground floor. In addition on the ground floor there is a laundry room, small reception room, bright lounge and a large bright kitchen/diner. On the first floor there are five bedrooms, one with en-suite facilities, a large bathroom with a toilet and a separate shower room with toilet. 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 people living in the home. The current range of fees in the home is from £940 - £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.V336953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took approximately eight hours, the majority of fieldwork being undertaken on 5th June 2007 and a brief follow up visit made on the 8th June 2007. The manager was present or available on both days. There were six people living at the home at the time of the inspection who had lived there for a number of years. There were no vacancies. This unannounced inspection included: discussion with five of the people living at the home, three of them independently; discussion with the manager and discussion with several support workers, two of them independently. Further information was obtained from a pre-inspection questionnaire, a tour of the premises and documentation kept at the home. What the service does well: The home provides very high quality care and support to to six people with a range of complex needs. The home meets their cultural and religious needs and enables them to be part of the wider Jewish community. Staff encourage people to be as independent as possible and support them to undertake a wide range of activities, both inside and outside the home. One person said that “staff talk to us about what we like”. Good quality care plans, risk assessments and other documentation assist staff to address people’s changing needs. People are also very well supported to address their healthcare needs. The home also benefits from strong and effective management. The home is decorated and equipped to a high standard, which people living there appreciate. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their needs and preferences reviewed on a regular basis, with input from health and social care professionals where appropriate, to assist the home in meeting people’s changing needs and preferences. EVIDENCE: The files of three of the six people living at the home were inspected and each contained comprehensive assessment information. This information covered the person’s physical, social, cultural and emotional needs and included up to date information compiled by both the home and by a range of external health and social care professionals. There was evidence of significant input where appropriate from health and social care professionals including psychiatrists and psychologists and that the home had ongoing contact with these professionals. The reports and documentation from the professionals were nearly all signed and dated by the professional that had written them. However, it was noted on one person’s file that there were behavioural guidelines that had been written by a professional but these were not dated and did not indicate which professional had written them. The manager was able to explain that the guidelines had been written by a psychologist and were current. A good practice recommendation is made that the where such documentation is received that the home records on the document who it was compiled by and the date it was received in the home. This is will assist Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 9 provide further clarity, especially for any new staff reading the file. The files inspected were well organised with information being easy to access. A requirement had been made at the last inspection that a copy of the current assessment for all people accommodated was kept on their file and this had been complied with. All of the people accommodated at the home have lived there for a number of years. The files showed that people’s needs were reviewed at regular intervals to ensure that any changing needs were understood and acted upon. Key workers are allocated to each person and evidence was seen of regular key worker sessions with individuals, which form part of the home’s overall system for monitoring need. People living at the home confirmed that they were involved in review meetings and knew who their key workers were. Key workers spoken to were able to describe the needs of people they key work and how the person was being supported with both their needs and preferences. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People’s needs are well recorded in their care plans to assist staff in meeting these. People are supported to maximise their independence by making as many decisions as possible for themselves, which they appreciate. People are also supported and guided in relation to taking appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: The three people’s files inspected all contained detailed and up to date care plans that were informed by current assessment information. The care plans were laid out in a logical sequence showing both the person’s assessed needs and their aspirations and preferences, and how they are supported to meet these. The plans are formally reviewed on at least a six monthly basis but are also reviewed monthly through key worker sessions with the person. The format of the record of the key worker sessions indicated that the needs and preferences recorded on the care plan were discussed at these sessions. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 11 People living at the home spoken to independently were aware of their care plans and confirmed that how they were supported was discussed in their key worker sessions. It was noted that the home was monitoring the gradual changing needs of one person living at the home and was actively negotiating with the person’s placing authority for additional resources. This was to further assist the home in continuing to meet the needs and preferences of this person in a sensitive and individual way in the future. A good practice recommendation had been made at the last inspection that the home should ensure that each person’s care manager is invited to a care plan review meeting on an annual basis and this had also been acted upon. Staff were observed interacting with people living at the home in an appropriately friendly and adult way throughout the inspection. The inspector was impressed when talking to people living at the home how they appeared to be generally confident about making decisions about their daily lives and the positive way they viewed the support they received from the home. Where restrictions were imposed on people these were recorded in their care plans and risk assessments and the people concerned were clear about this. One person who travels independently stated that they decide where they want to go and then phone the staff when they get there to let them know they are OK. Another explained how they liked to travel, including abroad, and that the staff assist and support them in researching this. Another person confirmed that staff talk to them about what they like and went on to say that they go to weekly residents meetings on a Saturday and “can say what we like”. People are supported to manage their finances as independently as they can, which was evidence by records seen and by talking to people living at the home. Each file inspected contained detailed and good quality risk assessments relating to that individual, these were current and subject to regular review. The risk assessments covered a wide range of potential risks that were relevant to that individual. They also gave guidance to staff on how to minimise the identified risks whilst at the same time promoting people’s independence. Risk assessments covered a number of areas including accessing the community, safety during food preparation and mealtimes and bathing. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home are encouraged and supported to participate in a wide range of activities of their choice, including within the wider community. They also enjoy contact with relatives and friends to the extent that they wish. People are also supported to enjoy healthy and nutritious meals that they like. EVIDENCE: People living in the home are encouraged to take part in a range of activities both inside and outside of the home. Two people have part time supported employment jobs with one of those people having been supported to achieve the national vocational qualification (NVQ) level 2 in administration. People are also supported to attend a local education college and a local resource centre and those spoken to confirmed that they enjoyed these activities. People are also supported to enjoy a variety of leisure activities including going to the theatre, bowling, cinema and eating out. Some of these activities are Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 13 organised by a Norwood social club called Links. The inspector was informed that two people regularly attend football matches at a North London Premiership football club. One of these people, spoken to independently, was a very keen supporter and showed the inspector a wealth of mementos and memorabilia and also had Sky television in their bedroom to help keep up to date with their team. People also access aromatherapy in the home and have access to a computer that is linked to the Internet. One person told the inspector that they researched where they wanted to go on holiday on the Internet and then negotiated with staff on making the necessary arrangements. In addition people are encouraged to develop their independent living skills by being assisted where necessary by staff in undertaking cooking and other household tasks as part of their weekly routine. The majority of the people living at the home have contact with relatives. This ranges from weekly contact with both the person’s relatives visiting the home and the person visiting their relatives at their home to annual contact at key times of the year. The manager stated that contact had been made with an organisation called “Stars in your Eyes” which assists and supports people with learning disabilities meet other people at arranged social functions. These functions provide an opportunity for people to meet other people in a safe environment who they may potentially develop a relationship with. However, the manager went on to say that this had met with a mixed reception from people living at the home, partly because of the location of the venue and partly because some people were not so keen when they had attended. The home supports people living there to enjoy a Jewish way of life to the extent that they wish. This includes a traditional meal on a Friday night and people at the home had enjoyed a Chanukah party in December. The inspector was informed that some people living at the home were more religious than others and although the Jewish culture is promoted and enjoyed by all, people are supported regarding this on an individual basis. People living in the home are also encouraged to take responsibility for routines in the house. Each person has a wire basket by their bedroom door that their post is put into. One person living in the home told the inspector that it was their job to sort the post. The home’s kitchen is properly arranged and equipped to promote the Jewish way of life and a certificate was seen on the wall of the kitchen to evidence this. People living at the home told the inspector that the menu for the following week is discussed at the weekly residents meeting. Each person is asked to choose a main meal for one day of the week and is supported in the preparation and cooking of this, staff choose the menu on the other day. The menu for the week showed a range of nutritious meals. The manager had arranged a session from a dietician for both residents and staff as part of the support to promote healthy meals. Various health and safety checks are regularly undertaken in the kitchen and records inspected showed that these Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 14 were satisfactory. Food was properly stored in the home including being labelled in the fridge and freezer where it had been removed from its original packaging. There was a satisfactory store of food in the home including a large bowl of oranges displayed in the kitchen, that the inspector was told people like. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are consulted and well supported with their personal care needs. Their health care needs are also well met including through referrals to a range of community based health professionals. However, if the home explores additional positive health screening inputs with those professionals this may further promote people’s future well being. People living at the home are protected by robust medication policies and procedures. EVIDENCE: All six people accommodated need some support with their personal care ranging from the occasional verbal prompt to physical assistance with identified tasks. Guidance for staff on how to provide this support was recorded on the individual care plans seen and issues relating to personal care were also recorded on risk assessments where appropriate. One person spoken to indicated that staff talked to them about their personal care requirements and that they were comfortable with the assistance they received from staff in this area. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 16 People living at the home are all registered with a G.P. and evidence was seen on files inspected that people are actively supported to attend a range of appointments with relevant healthcare professionals as required. These appointments included with their: G.P., psychiatrist, psychologist, physiotherapist, chiropodist, dentist and a range of hospital appointments. At the last inspection a requirement was made that all people accommodated are supported to have a current optical check and evidence was seen that this had been complied with. People are also supported to have their weight checked on a regular basis and up to date records of this were seen. One person was supported through a complex physical health difficulty since the last inspection that had included admission to a specialist hospital. That person was spoken to and stated that they were now much better and indicated that they could now get on with a range of activities that they enjoyed. At this inspection it was noted that all four women living at the home had signed forms stating that they did not want to attend health screening appointments for cervical smears or for breast screening. This was discussed with the manager who stated that the staff were trying to promote the benefits of such screening but the women were clear they did not want to attend these appointments, including signing the form stating this. A good practice recommendation is made that the home seeks further advice from health care professionals regarding any alternative ways of promoting positive health screening in these areas. The home has a satisfactory medication policy that includes guidance on kosher requirements. The home’s medication administration procedures were inspected and were of a high quality. People living at the home have a medication profile in their files. This includes what medication they have been prescribed, what the medication is prescribed for, common side effects that may occur and any known allergies the person may have. Guidance was recorded for staff regarding medication that is to be administered when required (PRN) and records of medication entering tand leaving the home were all current. Arrangements for storing medication in the home were satisfactory and the medication and medication administration record (MAR) charts for three people were inspected and were satisfactory. Edgeworth Crescent 55 DS0000010426.V336953.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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are able to express their views and concerns, have these taken seriously and appropriately dealt with. However, further identified detail is needed in the complaints procedure and residents and other stakeholders may benefit from information about how to raise concerns being displayed more prominently in the home. People living in the home are protected by satisfactory adult protection policies and procedures that staff are aware of. EVIDENCE: The home has a detailed complaints procedure including that complaints can be referred to the Commission if the complainant remains dissatisfied with how their complaint has been dealt with. However, although the contact details of the Commission are shown separately in the home’s statement of purpose they are not included in the complaints procedure, which is a separate, stand alone document. A requirement is made regarding this. People living at the home that were spoken to were clear about how to raise concerns and indicated that they did raise concerns when they felt the need and that these were acted on promptly by the home. A good practice recommendation is also made that a copy of the complaints procedure is displayed in a suitable communal area of the home. This is so that it is readily accessible to people living at the home and to relatives and other stakeholders who visit the home. The manager stated that the no complaints had been received by the home in the past 12 months. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 18 The home has a satisfactory adult protection policy and also has a copy of the London Borough of Barnet’s adult protection procedure, the local authority for the area the home is situated in. There was also a flow chart displayed in the office showing action required using that authority’s procedures, should an allegation or disclosure of abuse be made. A requirement had been made at the last inspection that all staff receive training on the protection of vulnerable adults and how to positively support people living at the home who have complex or challenging behaviours. Evidence was seen that this requirement had been complied with. Staff spoken to were aware of the action they needed to take should an allegation or disclosure of abuse be made. Staff were also able to speak knowledgably about how they positively supported people living at the home who have complex needs and who may also demonstrate behaviour that challenges. Edgeworth Crescent 55 DS0000010426.V336953.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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is comfortable, well decorated and which meets their needs. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home as well as for those that visit it. EVIDENCE: The home is equipped and decorated to a high standard, well maintained and provides a comfortable home that meets the needs of the people living there. On the ground floor there is an entrance hall leading to a main lounge, a smaller lounge that contains a personal computer linked to the internet, a large kitchen/ diner, one accessible bedroom that has en-suite facilities and a toilet/ bathroom. The communal facilities on the ground floor are also accessible to all people living at the home. The first floor consists of five bedrooms, one ensuite, a bathroom/ toilet, a separate shower/ toilet and a staff office. One person invited the inspector to have an independent chat in their room, which had been highly personalised. The main lounge contains an attractive Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 20 aquarium that people living in the home take responsibility for. The home also has a large pleasant rear garden that is accessed from a patio. The patio is in need of significant structural repair and the manager stated that arrangements were in hand to have this work undertaken. The home’s laundry facilities are also on the ground floor of the home and are satisfactory. The home has an effective infection control procedures and the home was clean and tidy throughout. Edgeworth Crescent 55 DS0000010426.V336953.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): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective staff team is able to competently address the needs of people living in the home. The home’s recruitment practises contribute towards the protection of people living in the home. They are also supported by staff who are appropriately trained in areas relevant to the needs of people accommodated and who are well supervised to assist them further in meeting needs of people living in the home and in their own personal development. EVIDENCE: The home had in post: a manager, deputy manager, 3 senior support workers and 4 support workers. An additional 1 support worker post was currently vacant but used to fund staff cover from approved bank staff employed by the provider organisation. The manager stated that the home did not use agency staff to minimise disruption to the home. The manager has achieved the national vocation qualification (NVQ) 4 in care, the deputy NVQ level 3 in care and the majority of the rest have achieved, or are working towards, NVQ level 2 in care with two of those working toward NVQ 3 in care. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 22 The staff rota was seen and showed 2 care staff on the early shift, 2 staff on the late shift and 1 waking night staff. In addition the home has 5 hours per day allocated for 1 to 1 work. The staff working on the day matched those recorded on the rota. The manager stated that her hours are in addition to the rota and that the deputy manager is included on the rota but has 1 or 2 days off the rota per week to undertake management tasks. A requirement was made at the last inspection that staff vacancies are filled and that staff are deployed to ensure the needs of people living in the home are met throughout the day and evening. This requirement had been complied with. Three staff files were inspected. These files contained evidence of a criminal records bureau (CRB) clearance and protection of vulnerable adults (POVA) checks obtained by the provider organisation prior to the staff member starting work, a clear application form, two references, proof of identity with a photograph and evidence of entitlement to work where appropriate. The manager was clear about the importance of operating a robust recruitment procedure to assist protect people living in the home. The manager stated that the provider organisation renews CRB checks on a regular basis. Requirements had been made at the last inspection regarding recruitment checks and that staff must have a current contract of employment, evidence was seen that these had been complied with. Each staff member has a training summary/ matrix that shows when training is undertaken and when refresher training in core subjects is due for renewal. These were sampled and seen to be satisfactory. The matrix covered the following areas: meeting the needs of people with epilepsy, health and safety, fire prevention, first aid, medication administration, challenging behaviour, mental health, protection of vulnerable adults, food hygiene and assessing risk. A requirement had been made at the last inspection regarding staff training in mental health and epilepsy and these had been complied with. Staff stated that the training they received was useful and that specific training was given to all staff on the Jewish way of life to assist meet the religious needs of people living in the home. Training for both staff and people living in the home was currently be undertaken by a dietician to assist promote healthy eating and the inspector was told that this was very enjoyable. The manager stated that all staff were supervised at least two monthly and documents sampled and staff spoken to evidenced this. Records sampled also showed that staff received annual appraisals and staff spoken to also confirmed this. Edgeworth Crescent 55 DS0000010426.V336953.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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home and staff benefit from the home being effectively managed although the manager still needs to formally verify her competency with the Commission to comply with legislation. People living at the home benefit from quality assurance processes by being involved in identifying how the service can continue to improve. Effective health and safety procedures contribute to protecting people accommodated, staff and visitors to the home. EVIDENCE: The manager was able to demonstrate a high degree of knowledge regarding the needs of the people living at the home, including how to address these in accordance with the Jewish way of life. She was also clear about the management issues and responsibilities of managing such a home. The Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 24 manager has several years management experience in a care setting including managing the home since November 2005. A requirement was made at the last inspection that the registered person ensures the manager submits an application to be the registered manager of the home. The inspector was disappointed that this had not been complied with and the requirement is restated at this inspection. A requirement was made at the last inspection that the results of the last quality assurance exercise are available in the service and an action plan prepared for the home to address issues relating to the service. This had been complied with and an action plan with realistic objectives for 2007/ 08 was given to the inspector. The home is also visited by a lay monitors approximately every 2 months as part of the overall quality assurance programme operated by the provider organisation. Copies of 2 recent reports were given to the inspector and showed a robust evaluation of their visit. The manager stated that as well as written feedback the provider organisation held meetings with the lay monitors and managers from the services involved to receive oral feedback and to discuss their findings a group. The home is also visited by a manager from the provider organisation on a monthly basis as part of the quality monitoring process. The manager stated that the results of these visits were usually discussed as part of her regular supervision. However the written reports of the last 3 visits were not available at the home as is required by the care homes regulations 2001. Hand written copies of these visits were obtained by the end of the inspection but a requirement is made regarding this as it is important that the written feedback from these visits is available to the manager in a timely manner. A range of health and safety documentation was inspected and was satisfactory. Satisfactory documentation was seen regarding: gas safety, electrical installation, portable appliance testing and testing of the home’s water supply to reduce the risk of legionella. The home’s fire log was inspected and contained evidence that the fire fighting equipment had been serviced and of a current fire plan and fire risk assessment. Two requirements regarding health and safety had been made at the last inspection in relation to servicing fire fighting equipment and training for staff. Evidence was seen that both of these had been complied with. Edgeworth Crescent 55 DS0000010426.V336953.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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 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 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 X 2 X 2 X X 3 X Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA22 Regulation 22 Requirement The registered person must ensure that the details of the Commission, including contact details, are included in the home’s complaints procedure so that people can refer complaints if they remain dissatisfied with how these have been dealt with by the provider organisation. The registered person must ensure the manager submits her registration application to the Commission to verify her competency and to comply with the care homes regulations 2001. (previous timescale of 31/12/06 not met). The registered person must ensure that reports of monthly monitoring visits undertaken to the home by the provider organisation are sent to the home in a timely manner to assist maximise the quality of the service the home offers. Timescale for action 31/07/07 2 YA37 8(1) 31/07/07 3 YA39 26 31/07/07 Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 27 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 YA22 Good Practice Recommendations The registered person should display a copy of the home’s complaints procedure in a suitable communal area of the home so that it is readily accessible to people living at the home and to relatives and other stakeholders who visit the home. Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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. Extracts may not be used or reproduced without the express permission of CSCI Edgeworth Crescent 55 DS0000010426.V336953.R01.S.doc Version 5.2 Page 29 - 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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