Inspection on 21/10/08 for Endsleigh House

This inspection was carried out on 21st October 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Endsleigh House 15/05/08

Endsleigh House 10/08/06

Endsleigh House 25/10/05

Endsleigh House 08/08/05

Endsleigh House 25/01/05

Endsleigh House 19/01/05

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Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Endsleigh House 44-46 Endsleigh Gardens Ilford Essex IG1 3EH     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Stanley Phipps     Date: 2 1 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Endsleigh House 44-46 Endsleigh Gardens Ilford Essex IG1 3EH 02085541167 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): endsleigh.house@gmail.com Mr Yuhya Roojee Name of registered manager (if applicable) Mr Yuhya Roojee Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users who can be accommodated is: 10 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Endsleigh House is a care home providing personal care and accommodation for ten individuals between ages 18-65 with a history of mental illness, who need support in order to live in the community. It is privately owned and managed by Mr Yuhya Roojee. The home is located on a residential street in Ilford and is close to all community facilities. These include a wide range of shops, pubs, the post office, entertainment Care Homes for Adults (18-65 years) Page 4 of 28 care home 10 Over 65 0 10 Brief description of the care home centres, parks and library facilities. Endsleigh House consists of ten single bedrooms, four of which are located on the ground floor. Access to the first floor is via two sets of stairs. There are four reception rooms on the ground floor, two of which is used for dining and the others for relaxation and viewing television. There is now an additional room where snooker is played and there are two designated smoking areas to the rear of the building. A rear garden that is domestic in scale is available for the enjoyment of all service users and is easily accessible from the kitchen and smoking area. A group of staff is on hand to provide twenty-four care and support to service users. A statement of purpose is made available to all service users and/or their relatives in the home and each individual is provided with a service user guide. Fees are charged at £800.00 per week and service users are expected to pay for their own toiletries, which are variably priced. Service users also have to make a contribution to their annual holidays where the cost is above £200.00. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The inspection consisted of a site visit which involved interviews and discussions with residents, staff and the registered manager. Written feedback was also provided by residents and staff working in the home and verbal feedback on the service was sort from external professionals. The inspection also included an assessment of policies and procedures, records required by regulation and a tour of the building. Detailed consideration was also given to the information provided by the registered manager in the Annual Quality Assurance Assessment (AQAA)document. Care Homes for Adults (18-65 years) Page 6 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have access to information about the home mainly through the homes statement of purpose and service user guide. However, the statement of purpose needs to be reviewed to cover the full range of specialist needs that are provided for, at Endsleigh House. All service users benefit from having a thorough assessment carried out on them prior to moving into the home. Evidence: Information is made widely available to prospectice residents, their relatives and social workers depending on who is supporting the individual to explore admission to the home. The most recently admitted resident indicated that he was aware of the services that the home offered prior to coming to live there. However, on examining the details regarding the types of needs, particularly the specialist needs that the home provides for - the statement of purpose did not go far enough to describe them. The impact of this is that prospective residents could be excluded from applying for admission or the registered person could be admitting service users with specialist needs that he is unable to provide for. The latter of the two could mean that the quality of care that the Care Homes for Adults (18-65 years) Page 9 of 28 Evidence: individual receives is compromised. The statement of purpose therefore needs to reflect the full range of specialist needs that are provided for at Endsleigh House. The case files of the most recently admitted resident was assessed amongst others and it was clear that the process was robust. Pre-assessment information about the individual was in place and the home carried out their assessment, out of which the care plan is devised. More importantly, a risk assessment and risk management plan was in place to ensure the safety and independence of the resident concerned. From speaking to the individual and assessing his personal records, it was clear that he was aware and invloved in the process. He was able to experience prior visits to enable him to test-drive the service, which was part of the assessment process. This is a positive part of the process, as it is important for residents to feel at home or at least get used to an environment that they are expected to spend a long time in. Care Homes for Adults (18-65 years) Page 10 of 28 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in the care planning and risk asessment processess now ensure that the specialist needs and safety of residents, are promoted within a risk management framework. Good evidence is in place to demopnstrate that residents make decisions in determining what is best for them. Evidence: From the care plans viewed improvements were noted in both the quality and content of the documents. There was much more information about specialist needs i.e. the mental health needs of residents. However, there was one case where more information should have been included in relation to the specialist needs of the individual. Residents are involved in their care planning, which is coordinated through the key worker system in the home. This process ensures that they are not only aware, but also involved in determining what is best for them. Care plans were developed from initial and ongoing assessments carried out with residents. Good evidence was in place to support the view that the care plans are regularly reviewed, Care Homes for Adults (18-65 years) Page 11 of 28 Evidence: which is positive. Discussions held with residents including the most recently admitted individual, informed that they feel able to make decisions in the home, which impacted upon them. There are various mechanisms for enabling residents to make decisions which include: key work sessions, residents meetings, informal discussions and annual residents surveys. Residents levels of participation vary depending on their individual levels of motivation and interests. It was noted that the finance policy had been reviewed around the process of obtaining compensation from residents. Futher enhancements needed to be carried out to improve transparency in how the whole process is to be managed. This was discussed at length with the registered manager upon which he was satisfied with the improvements he had to make to ensure that the process was more transparent. There was an improvement in the risk planning and risk management practices in the home. All risk assessments were updated and were the least restrictive, taking residents choice and independence in mind. Staff spoken to understood the importance of risk assessments and the relationship between safety and the promotion of residents independence. Both the care plans and the risk assessments were linked and found updated at the time of the inspection. A missing persons procedure is in place at the home to ensure that residents are safe, should they decide to leave the home. Care Homes for Adults (18-65 years) Page 12 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to participate in activities that are in line with their interests and aspirations. They are also supported to maintain and develop networks of their choice. Improvements in the quality of the financial policy now give greater rights to residents, although further improvements are required to the document. Meals provided at the home are reflective of the nutritional needs of the residents living there. Evidence: Each resident has an individual plan of activity, which is generally drawn up with their key worker. Residents therefore get to choose what they wish to get involved in following whcih the resources are allocated to enable them to achieve their objectives. One resident attends university three times per week and he has been progressing quite well in his choosen programme of study. He is quite proud of his achievement to Care Homes for Adults (18-65 years) Page 13 of 28 Evidence: date and spoke of getting a job once he has completed his studies, and relocated to a less supported environment. Three other residents are engaged in day centre activities while another individual was in the process of taking up information technology at Redbridge Adult Learning Centre. Residents are therefore engaged in activities that are in line with their choice and best interests. Residents continued to make use of the the local facilities such as the parks, shops, cinema and day centres. They were quite familiar with their community environment and staff were instrumental in enabling this. One individual remarked: I enjoy going up to the local town centre to get my bits and bobs - which I do on my own. Feedback received from external professionals indicated that residents do make use of their community resources which is positive. From the records viewed, there was evidence that residents are engaged in a wide range of leisure activities both internally and external to the home. One of the internal entertainment resources, is a pool table, which is available to all residents living in the home. They also have entertainment via the television and most have their personal entertainment systems, which they use for their personal enjoyment. From observation residents were clearly in control of how they spent their leisure time and this included their vacation and day trips which they enjoy. Residents also benefit from taking part in their summer barbecue and social events such as - birthday and other festive events. Feedback received from residents confirmed that they were very pleased with the range of leisure activities provided by the home. Residents continued to enjoy positive relationships that have been developed with friends and families. A visitors policy is in place and relatives and friends are invited to attend events held in the home. One resident confirmed that he stiil maintains good contact with his sister and recounted the last visit he made to his parents. From records seen, it was clear that relatives and friends are encouraged to visit the home. During the course of the inspection residents were observed being addressed by their preferred names, as they went about their individual routines. In discussion with some - they informed that they are able to go to bed and get up, at a time of their choosing. They also reported that staff knock on their doors prior to entering their rooms. Advocacy information is available to all residents via the notice board and the key worker system is used to ensure that rights and needs are respected and provided for. It was clear from looking at the documentation, including the reviewed financial policy, that the rights of residents are more respected than previously. The policy referred to, still required further improvements, which were discussed with the registered manager. It was advised that the amendments would be made to the policy to ensure that there is greater transparency in the process of recovering compensation from Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: residents living in the home. Residents confirmed that they actively choose the type of food they ate. Menus were in place and they appeared to be balanced and and varied. On the day of the site visit the evening meal consisited of chicken and egg fried rice and residents were delighted with the meal. Mealtimes and the whole concept of dining was very much down the residents choice. Residents were very relaxed during the meal period and some chose to eat later on in the day and this was facilitated by the saff on shift. There was a good supply of food in the home, which was appropriately stored at the time of the visit. All residents reported that they were happy with the meals provided at Endsleigh House. Care Homes for Adults (18-65 years) Page 15 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents enjoy personal support in a manner that they are pleased with. Sound arrangements are in place to meet both their healthcare and emotional needs. This is generally reinforced by the medication practices in the home, which promotes residents independence, but could be enhanced through better recording of all medication entering the home. Evidence: From the feedback received, all residents were happy with the way in which they received personal support. This is coordinated primarily through the key worker system used in the home. Residents have their own style of dress, which is unique and distinct from each other. Information gathered through the assessment process is used to determine the preferences and interests of each resident.This forms the basis of the interactions and interventions made by staff with residents. Residents stated that they feel respected by staff and this goes towards the maintenance of a positive relationship between them. Clear records are held in the home of all appointments that are attended by residents Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: and this includes professional healthcare appointments. All residents are registered with a GP and have at one time or another attended the surgery. The same is true for the special needs of the residents living in the home in that they are seen regularly or as necessary by a psychiatrist or other professional from the community mental health team. There was also evidence that residents have access to the opticians, dentist and audiologist as necessary. All residents responded positively about the support they receive from staff in the promotion of their health and welfare. A key part of their healthcare support is the support provided with medication. At the time of the visit two residents were capable of managing their medication with little staff support, which is positive. An updated medication policy is in place and this includes provisions for the self-administration of medication. All staff have had the benefit of medication training to ensure that they are competent to provide appropriate support to residents with their medication. The registered manager overseers medication practices in the home and medication storage was generally good, at the time of the visit. However, evidence was found to indicate that not all drugs are recorded on entering the home. This needs to improve to comply with the safe handling of drugs regulations and to ensure the safety of both staff and residents in the home. Care Homes for Adults (18-65 years) Page 17 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are better safeguarded and their rights promoted through improvements carried out by the registered manager in; the handling of complaints and the safeguarding of vulnerable adults. Evidence: A complaints record is now in place at the home. More importantly, an assessment of the handling of a complaint, indicated that the actions taken to resolve the complaint were recorded. This is positive. An updated complaints procedure was also in place for the benefit of residents, staff, relatives and external parties as and when required. Residents spoken to were happy with the format of the document and from the feedback received they were very clear as to who they would raise their complaints with, should they be unhappy with any aspect of the service. Staff spoken to showed an awareness of the need to support residents to raise concerns as and when they become unhappy with the services at Endsleigh House. External professionals spoken to were also of the view that residents were better safeguarded with the improvements in the quality of recording now in place at the home. At the time of the visit there were no safeguarding issues in the home as the registered manager complied with a previously issued statutory enforcement notice issued by the Commission for Social Care Inspection to ensure that adults are safeguared. There were also clear improvements with the quality of recording by staff Care Homes for Adults (18-65 years) Page 18 of 28 Evidence: working in the home, particularly in relation to incidents and the management of them. The registered manager and other staff had undertaken safeguarding adults training following the last inspection and this would go a long way into residents being better safeguarded at Endsleigh House. A safeguarding adults protocol was in place and available to all staff. Care Homes for Adults (18-65 years) Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents contonue to live in an environment that is well--suited to meet their needs. The design and layout of the environment matches their lifestyles. Good maintenance practices ensure that the home remains fit for purpose, and a safe place to live. Evidence: Although the inspection was unannounced the home was clean, bright and airy. Some of the residents were at home, while others were out. Residents were generally relaxed in various parts of the building at the time of the visit. It was clear that they had access to all parts of the home, which they made full use of. There are designated smokng areas for the benefit of residents that do so. Feedback received from residents indicated that they were extremely pleased with the quality of the environment at Endsleigh House. The newly converted bedroms in the loft remained unoccupied as the registered person had not yet applied for a variation to increase the number of residents to be accomodated at Endsleigh House. The laundry facilities are designed to ensure that residents have opportunities to develop skills in this area. It was clean and hygenic on the day of the visit and there was evidence to suggest that each resident has a day on which they would use the facility. An infection control policy is in place for the benefit of staff and residents alike. Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: The laundry equipment is designed to clean soiled linen and appropriate arrangements were in place for their maintenance. The location of the laundry facilities are such that soiled linen is kept well away from the kitchen area and this minimises the risk of the spread of infection. The water facilities do comply with the Water Supply Regulations 1999, which make the environment safe. Residents and external professionals commented positivley on the cleanliness of the environment. Care Homes for Adults (18-65 years) Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in the training provided to staff now ensure that residents are not only supported by a staff team that is motivated to so do, but by a team that has grown both in confidence and competence. Good recruitment practices ensure that residents are safe living at Endsleigh House. Evidence: At the time of the visit the manager and two support staff were on duty. One of the residents had just returned from attending his Care Programme Approach review accompanied by the registered manager. There were adequate staff of duty to support residents with their objectives and from the records seen, various aspects of training had been provided since the last inspection. Staff were observed engaging with residents in a very calm manner, even if a resident became anxious. The staff on duty had a good understanding of the residents needs, as well as the interventions required to support each individual in promoting harmony and minimising distress. There was evidence from records that staff were capable of making appropriate referrals to external professionals e.g. the community psychiatric nurse or the GP, when specialist interventions were required. There was also evidence of improved recording and detail of interventions made by staff since the last inspection, which is positive. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: The recruitment records of the most recently employed staff were examined and found to be in order. All checks required by regulation had been carried out prior to the staff commencing employment at the home. This ensures that unsuitable staff are kept away from vulnerable residents and in essence promote residents safety. All staff have a face to face interview and the recruitment practices were in line with best practice. There were improvements in this area in that staff were provided with more appropriate training to carry out their functions of supporting people with mental health problems. At Endsleigh House some residents have complex needs - some of which include having a dual diagnosis and it was positive to see that the training was pitched along those lines. As important was the fact that staff were also given some exposure to substance misuse training which would go a long way in understanding how best to support and help residents lead meaningful and healthier lives. The registered manager is aware that he is to develop a training and development profile for each staff member and has started on this. Each staff have a copy of the General Social Care Councils code of conduct, which provides them with information around the standards of pratice required in promoting the health and welfare of all residents living at Endsleigh House. Residents are therefore in a better position to receive a good standard of care in the home. Care Homes for Adults (18-65 years) Page 23 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements in management practices and the provision of specialist training for staff, make it possible for vast improvements to the quality of service provison at Endsleigh House. Good mechanisms are in place for the service to develop, as well as for ensuring the health and safety of residents and staff. Evidence: The manager is a registered mental health professional who has also achieved the Registered Managers Award. He has updated his knowledge since the last inspection in - First Aid and Safeguarding Adults. He has managed the home from inception and has a good rapport with both residents and staff. He operates an open-door policy, which seems to suit both groups, particularly when residents become anxious. His experience has been useful is supporting staff to make appropriate interventions when there are complex circumstances occurring in the home. Feedback from residents indicated that they were pleased with the way in which the service was managed which could be summed up in one of the comments made by a resident- Rojee looks after all of us here. Care Homes for Adults (18-65 years) Page 24 of 28 Evidence: A key improvement in this area(management) has been the review of the finance policy, which would lead to a review in how compensation is sought from residents. That coupled with the introduction of the equality and diversity policy should ensure that the rights of residents are promoted and preserved. It must also be noted that the registered manager has worked collaboratively and collectively with the Commission to ensure that standards of practice in the home is such that it improves outcomes for the residents living there. In so doing he has complied with the statutory enforcements notices served by the Commission along with all the statutory requirements of the last inspection report - which is a testament to his committment to improving his service. It is also a testament to his professional integrity. An annual development plan was in place at the home and although an annual resident survey had not been carried out, plans were on the way for one to be done. There was good evidence to confirm that the service is consistently monitored by the registered manager in areas such as medication, care planning, health care provision, complaints, general policy implementation and safeguarding adults. Reviews are regularly held at the home, one of which is held annually with external professionals. It is at this meeting that the views of external professionals are sort on the quality of the service provision at Endsleigh House. Residents are therefore assured that action would be taken to develop the service involving their views and the views of significant others. The health and safety file was assessed and found to be generally in good order. This included records on fire, electrical and gas safety, and for all appliances cited in the home. Food storage was assessed and found to be good and it was reported that the service achieved a four star rating for Food Safety from the London Borough of Redbridge. which is commendable. All staff have the benefit of an induction that involves health and safety and safety signs were appropriately located throughout the home to ensure a safe environment. Risk assesments were in place for all residents as well as for safe working practices such as fire, food hygiene and first aid. The health and safety policies were updated and accessible to all staff, and a good record is held of accidents and incidents in the home. Residents can feel assured that the eenvironment at Endsleigh House is safe to live in. Care Homes for Adults (18-65 years) Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 2 4 Review the statement of purpose to fully indicate the range of specialist needs that are provided for at Endsleigh House. To ensure that prospective service users have the most accurate information on which to make a decision to live in the home. 09/03/2009 2 20 13 The registered person must ensure that a record is kept of all drugs entering the home. To ensure that an audit trail can be carried in identifying how and when drugs are used inthe home. 05/04/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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