Inspection on 11/05/07 for Greenfield Road 9

This inspection was carried out on 11th May 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenfield Road 9 05/06/08

Greenfield Road 9 24/04/06

Greenfield Road 9 31/10/05

Greenfield Road 9 25/04/05

Greenfield Road 9 25/10/04

Greenfield Road 9 14/07/04

Greenfield Road 9 04/03/04

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 Greenfield Road 9 London N15 5EP Lead Inspector Susan Shamash Key Unannounced Inspection 11th May 2007 12:30 Greenfield Road 9 DS0000010810.V333413.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 Greenfield Road 9 DS0000010810.V333413.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. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greenfield Road 9 Address London N15 5EP 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 8809 7044 F/P 020 8809 7044 companioncare@hotmail.com Companion in Care Limited Mr John Ajumobi Care Home 3 Category(ies) of Learning disability (3), Mental disorder, registration, with number excluding learning disability or dementia (3) of places Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 3 people of either gender who have a mental disorder (MD) or who have a learning disability (LD) Date of last inspection 24th April 2006 Brief Description of the Service: Greenfield Road is registered as a care home for a maximum of three adults between the ages of 18 and 65 who may have mental health problems or learning difficulties. The home’s registered provider has been changed in October 2003 to Companion in Care Ltd. The company owns two other homes in Brent and Newham. The home consists of a large three-storey town house situated in South Tottenham in the borough of Haringey. There are good public transport links to the area and a good variety of shops and other amenities are close by. On the ground floor, there is a kitchen/ lounge/diner, a toilet and bathroom, with access through the lounge to the garden and a laundry area. Two bedrooms and an office are situated on the first floor. A toilet and bathroom and two more bedrooms are located on the second floor. None of the bedrooms are en-suite. There is a small garden at the front of the property and a large paved garden at the rear. The home is not suitable for people with mobility problems. The stated aims of the home are to provide care, support and attention to people living at the home to enable them to lead as normal a life as possible. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. The current scales of charges are from: - £500 to £550 per week. There are no other additional charges. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately six and a half hours. On duty was one support worker who assisted me throughout the inspection, followed by a newer support worker who began her shift at 3pm. The registered manager/provider was unavailable at the time of this inspection as they were undertaking a training course. Presently the home is fully occupied. The people living at the home have mental health problems and have lived at the home for a number of years. I spoke to two of the three people living at the home individually and positive feedback was provided about the service. I conducted a tour of the building, sampling three residents’ care plans, observing staff with people living at the home and examining policies and procedures. What the service does well: What has improved since the last inspection? As required at the previous inspection, the Statement of Purpose had been amended to include all the communal room sizes. Residents’ care plans were being reviewed, monitored and updated appropriately, and reflected individuals’ goals and aspirations. The shower unit in the bathroom had been replaced and the cockroach problem in the kitchen had been addressed as required and separate handwashing facilities had been provided in the kitchen. The bathroom and communal areas of the home had also been redecorated. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 6 Portable Appliances Testing and Electrical Installation certificates were available for the home and Regulation 26 visits were being undertaken at least once a month. What they could do better: It remains required that residents’ contracts need to be reviewed and amended to ensure that their interests are fully protected. Records must be maintained of all health care appointments offered to people living at the home including those that they refuse to attend, and guidance provided to them. It remains required that the medication policy be amended to included a section on Controlled drugs. The complaints procedure for the home must be updated to include current details for the CSCI. Relevant people need to be provided with repairs and replacements in their bedrooms and the leak in the shower room on the first floor must be repaired. It remains required that all the outside windows be cleaned regularly. Soap and hand drying facilities must be provided in the laundry, and the leak and broken tiles in the laundry must also be repaired. It remains required that the current staffing levels in the home must be reviewed. Evidence that this has been undertaken including an action plan of the proposal must be submitted to the Commission. It remains required that all care staff must undertake fire awareness and mental health training and an appropriate sexual awareness course. Evidence must be provided that the manager has undertaken the equivalent of NVQ level 4 in care and management. Reports of monthly unannounced visits to the home undertaken on behalf of the registered provider must be sent to the local CSCI area office each month. A quality assurance audit must be undertaken for the home at least annually including feedback from all stakeholders such as residents, staff, relatives, health care professionals and social workers. A record must be maintained of any properties kept on behalf of people living at the home including cashbooks, passports etc. Evidence must be provided that the home has consulted with the London Fire Emergency Planning Authority (LFEPA) fire officer with regards to fire doors being propped open and the home’s water supply must be tested for Legionella. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 7 Recommendations are made that the Statement of Purpose and Service User Guide be updated to be more user friendly and a selling tool for the home, that staff undertake ‘person centred planning’ training, that a summary of each resident’s individual finance arrangements be recorded on their care plan, that residents be supported to have an annual holiday away from the home, that more fresh vegetables be available in the home, that a computer be provided in the home, and that an air dryer machine be provided in bathrooms/toilets if paper towels are not suitable for residents. It is of concern that several requirements have been restated in this report. Any unmet requirements impact upon the welfare and safety of people living at the home. Failure to comply by the revised timescale will lead to the Commission for Social Care Inspection considering enforcement action to secure compliance. 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. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a statement of purpose and service users guide providing people considering living at the home with sufficient information to make a choice about living in the home, although this information could be provided in more accessible formats. Prospective residents’ needs are assessed prior to their admission to ensure that these can be addressed appropriately. Residents’ signed contracts still do not reflect the correct services offered by the home so residents cannot be sure that they are receiving the appropriate care offered to them. EVIDENCE: At four previous inspections it was required that the home’s Statement of Purpose be updated to reflect all the room sizes in the home. I was shown the updated document, which contained a list of the bedrooms and communal areas alongside their measurements as appropriate. A copy of this updated document should be sent to the local CSCI area office. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 10 It remains recommended that the Statement of Purpose and Service User’s guide be available in a user friendly format and can be used as a selling tool for the home. Detailed assessments were available in the files of the three people living at the home, indicating that appropriate information was obtained prior to their being admitted. This was confirmed by staff and residents spoken to. Contracts relating to each individual’s care were on file. However the contract format continues to state that the home does ‘not provide personal care under the Domiciliary Care Agencies Regulation 2001’ as noted at the previous inspection. It remains required that this statement must be either removed or amended from all relevant contracts. Contracts also do not specify the room to be occupied by each person living at the home. This is also required. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are monitored and reviewed regularly to ensure that the changing needs of people living at the home are met appropriately. People living at the home are supported to make decisions about their lives and to take informed risks to develop their independence skills. EVIDENCE: All people living at the home have a care plan in place and three care plans were examined. As required at the previous inspection, each care plan had been updated and evidence was available that they were reviewed at least sixmonthly so that they reflected individuals’ current day-to-day goals or aspirations. These included mental health needs, budgeting, activities, personal hygiene and daily activities. Care plans were signed and dated by people living at the home and residents spoken to advised that they were consulted about their care and support needs. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 12 It remains recommended that ‘Person-Centred planning’ be considered for preparing and setting up care plans with individuals, to give residents more autonomy and ensure a holistic approach. One of the people living at the home manages their own finances. One person’s money is managed by the home and the placing authority manages the other person’s money. At the previous inspection it was noted that although it was evident that each resident received a weekly allowance, there was no clear documentation with regards to who manages whose personal monies. Whilst inspecting residents’ finances, clear information was made available to me, evidencing that each persons’ monies were managed appropriately. Monies stored on behalf of them were clearly recorded, as were details of monies withdrawn from bank accounts and how these had been spent. Residents confirmed that their monies were available to them whenever needed, as appropriate. However it remains recommended that a summary of each resident’s individual finance arrangements be recorded on their care plan for clarity, to ensure that they are fully protected. A requirement is also made under Standard 41 regarding the recording of documents being stored on behalf of people living at the home. People living at the home are offered opportunities to participate in the day-today running of the home, through monthly resident meetings and annual questionnaires. Risk assessments regarding individual’s personal care were in place, and these had been reviewed and updated as required. At the previous inspection the inspector advised that different approaches be tried with regards to highlighting to people the dangers of smoking in their bedrooms. It was advised that residents could undertake fire awareness training with care staff to reinforce the dangers. However staff advised that no residents had been interested in joining in this training when it was arranged, and this was confirmed by those spoken to. Risk assessments were available regarding smoking for all people living at the home indicating that they had been consulted and agreed to the safeguards recorded. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home know that their rights are respected and their independence is supported. They are encouraged to maintain contact with family and friends. They are supported to engage in activities of their choice and utilise facilities in the local community. Meals in the home are good offering both choice and variety and meeting the cultural needs of people living at the home. EVIDENCE: Staff advised that one person living at the home has a voluntary job, packing gifts into boxes. The others go out to support group drop-in sessions, the local café or shops and Holloway Road market. I observed staff interaction with people living at the home and this was appropriate. The home ensures that individual rights are respected and Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 14 people’s independence is supported appropriately and monitored accordingly. During the course of the inspection residents came in and out of the home independently, all having their own key to the door. Timetables of each person’s daily activity programmes were displayed in the office, and these indicated that each person had full days’ activities planned. One resident spoken to stated that they liked doing their own thing, another advised that they generally enjoyed the activities planned for them. Activities recorded in daily records included shopping, household chores, cooking, bus rides, a support group drop-in, visiting friends, resident meetings, going to the market, post office, betting shop, gym and cinema. Staff advised that days out to the coast and parks and a barbeque were being planned for the summer. Discussion with people living at the home indicated that they would like to have a holiday away from the home. It is recommended that residents be supported to have an annual holiday away from the home as indicated by their expressed wishes. As recommended at the previous inspection, a notice board had been made available for person living at the home, with useful information posted. There is a visitors’ policy, which states that visitors are welcome at the home at any reasonable time and with the consent of the people living at the home. It was evident on individuals’ files that family contact is maintained. Most of the residents’ families live close by. One person’s family lives abroad and they keep in contact by phone and letter. The home continues to provide at least one hot meal during the day, in the evening, with breakfast and a light lunch also provided. I observed residents making cups of tea at their leisure during the inspection. As required at the previous inspection, action had been taken to deal with cockroaches in the kitchen area. Although the kitchen was well stocked with fresh fruit, dried, tinned and frozen produce, there was not much choice of fresh vegetables available. It is recommended that more fresh vegetables be available in the home to ensure a nutritious diet for residents. Greenfield Road 9 DS0000010810.V333413.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are supported by the home in the way they prefer. The home’s procedures could be further improved to ensure residents who perpetually refuse, continue to be encouraged to attend appointments to promote their health. People living at the home know that they are safeguarded by the policies and procedures for dealing with medicines, promoting good health. EVIDENCE: All people living at the home are independent with regards to personal care, but the staff advised that at times they might need prompting to ensure good personal hygiene is maintained. At a previous inspection it was required that staff undertake training to provide them with the support and guidance they need to support residents’ sexuality needs appropriately. Staff advised that the registered provider had been researching relevant courses but this training had not yet been provided. This remains required. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 16 Healthcare records were detailed indicating appointments attended by people living at the home. However in cases where residents habitually refused to attend dentist and optician appointments, there was no evidence that they were being offered appointments or counselled about the importance of attending these services. A requirement is made accordingly. One person living at the home is working to control their weight, with support from staff to attend the gym twice a week. Medication was checked and was in good order with no gaps in the medication administration records and appropriate storage arrangements in place. At the previous inspection it was required that the medication policy be updated to include a section relating to control drugs. However examination of the policy on this occasion indicated that this had not yet been undertaken. This requirement is restated. Greenfield Road 9 DS0000010810.V333413.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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home know that their views are listened to. Staff have a good practical knowledge and understanding of adult protection issues which protects people living at the home from abuse. EVIDENCE: The home has in place complaints and abuse policies and procedures. However the complaints procedure needs to be updated to include the new address for the local CSCI area office. No complaints had been recorded since the previous inspection. Records of staff training around the Protection of Vulnerable Adult with the local authority were on file. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 18 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, 25, 26 and 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is adequately decorated, clean and hygienic, however, a number of repairs and replacements are required, to ensure the home is safe and an inviting place for people to live in. EVIDENCE: People living at the home stated that they are generally happy in the home, and their bedrooms are comfortable to meet their individual needs. Over the years the manager has improved a number of areas of maintenance within the home. This has included the installation of a new kitchen and new stairway and hallway flooring. As required at the previous inspection, the communal areas of the home had been redecorated and the bathroom and toilet on the top floor had been refurbished. However staff advised that there was a leak in the shower room on the first floor and this must be repaired. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 19 The hazardous electrical plugs in a resident’s room had also been made safe as appropriate. It was also required that the outside windows, especially the top ones, be professionally cleaned. However this had not yet been undertaken, staff advised that the provider had been having difficulty locating a window cleaner. This remains required. Residents’ bedrooms were generally in a good state of repair, however inspection of the rooms and discussion with residents revealed that one resident wanted a lampshade in their bedroom, another needed their chest of drawers repaired or replaced and one resident needed a new mattress or bed and their bedroom walls repainted. As required at the previous inspection separate hand-washing facilities had been provided in the kitchen, and the cockroach problem, had been addressed. However a broken kitchen cupboard door must be repaired. The laundry facilities can be accessed by the garden but did not include any soap or towels for hand washing. It is therefore required that soap and hand drying facilities be provided in the laundry, and the leak and broken tiles in the laundry must also be repaired. No computer is available at the home, and this is recommended for more efficient running of the home on behalf of residents. It is also recommended that an air dryer machine be provided in bathrooms/toilets if paper towels are not suitable for residents, to ensure hygienic procedures within the home. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A competent and effective staff team supports people living at the home. The registered person however, has failed to review the staffing levels in the home. Therefore residents’ care needs may be put at risk due to care staff not being able to support individuals appropriately. Appropriate recruitment procedures are in place for the home to protect residents. However further staff training is required in sexual awareness, fire safety, mental health and manual handling to ensure that all the needs of residents are met appropriately. EVIDENCE: The rota was displayed on the staff notice board. It was evident that apart from the manager on the rota there are another five staff members employed. Two full time workers cover almost all the sleeping-in duties, with the same days off each week, and both work each weekend. In discussion with the support workers the rota was discussed. One staff member advised that if they wished they could request a weekend off at anytime. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 21 At the previous inspection the subject of annual leave was also discussed, as it was evident that no annual leave had been taken. Discussion with staff on this occasion revealed that staff had taken annual leave as appropriate. At the previous three inspections the staffing levels have been discussed. It was concerning that although this had been discussed at great length with the registered manager/provider, the staffing levels have still not been reviewed. The rota showed no evidence that as-and-when staff workers were being used to provide occasional one-to-one support for residents outside of the home. This requirement is restated. It was not possible to examine all staff files during the inspection as the manager was not available. However I was able to inspect training records and talk to two staff members. At the previous inspection four care staff personnel records were examined and all documents required for employment were in good order. At the previous inspection the service’s training deficiencies identified were fire safety, mental health and manual handling. It remains required that further training be provided to staff in these areas in addition to an appropriate sexual awareness course. Supervision was discussed with support workers. They both stated that they have supervision with their line manager once every two months and discussed the training that they had undertaken including first aid, food hygiene, protection of vulnerable adults, infection control. One support worker was currently undertaking NVQ level 2 in care. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 22 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 and 42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living at the home benefit from a home that is run well and can be confident that their views are sought although there is insufficient evidence that they are always taken into account. Improved recording procedures are needed to ensure that residents’ properties are safeguarded as far as possible. Residents are generally well protected from harm by the home’s health and safety procedures. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is qualified and experienced to run the home and meet the Statement of Purpose’s, aims and objectives. The manager has a Diploma in Social Work and has extensive experience of working with people who have mental health problems. However, there is no evidence that the manager has undertaken a qualification in NVQ level 4 in management and care or equivalent as required at the previous inspection. This could not be verified as the manager was not available at the time of this inspection. Evidence of this qualification must be sent to the local CSCI area office. It was also required that the registered person ensures that the results of residents’ questionnaires surveys are published and made available to person living at the home and their representatives and other interested parties. Copies of the questionnaires were completed and on file. However, no annual report was in place. A quality assurance audit must be undertaken for the home at least annually including feedback from all stakeholders such as residents, staff, relatives, health care professionals and social workers. Results of these audits must be provided to the local CSCI area office. It remained evident from the findings that the registered person does not submit to the Commission, Regulation 26 visit reports as part of the ongoing quality assessment of the home, although these visits are being undertaken monthly as required. It remains required that these be sent to the CSCI on a monthly basis. Inspection of the management of residents’ finances indicated that appropriate procedures are generally in place, with signed records available of all transactions made. Residents confirmed that they could access their monies whenever needed. However there is no record maintained of any properties kept on behalf of residents including cashbooks, passports etc. This is required to ensure their protection from financial abuse as far as possible. Health & Safety certificates were checked and are in place. However, although Electrical Installation and Portable Appliance Testing certificates were available as required at the previous inspection, there was no evidence that a Legionnella test had been undertaken as required. The fire blanket in the kitchen had also been serviced as required. The environmental and fire risk assessment was in place and regular alarm tests and fire drills were being organised. As recommended a zone map had been put in place on the fire panel for the home. It remains required that evidence be provided that the home has consulted with the London Fire Emergency Planning Authority (LFEPA) fire officer with regards to fire doors being propped open. Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 X 4 X 5 2 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 2 25 2 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X 2 2 X Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5(1)(c) Requirement The registered person must either amend or review the residents’ contracts that are in place referring to personal care and Domiciliary Care Agencies Regulation 2001. (Previous timescale of 30/05/06 not met). The room to be occupied by each resident must also be specified on each contract. The registered person must ensure that records are maintained of all health care appointments offered to residents including those that they refuse to attend, and guidance provided to them. The registered person must amend the medication policy to included a section on Controlled drugs. (Previous timescale of 30/05/06 not met). The registered person must update the complaints DS0000010810.V333413.R01.S.doc Timescale for action 29/06/07 2. YA19 17(1)(a) Sch 3(3m) 29/06/07 3. YA20 13(2) 29/06/07 4. YA22 22 29/06/07 Greenfield Road 9 Version 5.2 Page 26 procedure for the home to include current details for the CSCI. 5. YA24 23(2bd) The registered person must ensure that relevant residents are provided with: • • • a lampshade in their bedroom, a repaired/new chest of drawers, a new mattress/bed, and repainted bedroom walls. 29/06/07 The leak in the shower room on the first floor and the broken kitchen cupboard door must be repaired. 6. YA30 23(2bd) The registered person must ensure that all the outside windows are cleaned regularly. (Previous timescale of 30/07/06 not met). The registered person must ensure that soap and hand drying facilities are provided in the laundry, and the leak and broken tiles in the laundry are repaired. The registered person must review the current staffing levels in the home. Evidence that this has been undertaken including an action plan of the proposal must be submitted to the Commission. (Previous timescale of 30/06/06 not met). The registered person must ensure all care staff undertake fire awareness, DS0000010810.V333413.R01.S.doc 13/07/07 7. YA30 23(2bd) 27/07/07 8. YA33 18(1a) 13/07/07 9. YA35 18(1ci) 30/08/07 Greenfield Road 9 Version 5.2 Page 27 10. YA37 18(1ci) 11. YA39 26 12. YA39 24 13. YA41 17(2) Sched 4(9) 14. YA42 13(4ab) 23(4) mental health and an appropriate sexual awareness course. (Previous timescales of 30/6/06 and 30/07/06 not met). The registered person must provide evidence that the manager has undertaken the equivalent of NVQ level 4 in care and management to the local CSCI area office. (Previous timescale of 30/07/06 not met). The registered person must ensure that reports of monthly unannounced visits to the home undertaken on behalf of the registered provider are sent to the local CSCI area office each month. (Previous timescale of 30/05/06 partially met). The registered person must ensure that a quality assurance audit is undertaken for the home at least annually including feedback from all stakeholders such as residents, staff, relatives, health care professionals and social workers. Results of these audits must be provided to the local CSCI area office. The registered person must ensure that a record is maintained of any properties kept on behalf of residents including cashbooks, passports etc. The registered person must provide evidence that they have consulted with the London Fire Emergency Planning Authority (LFEPA) fire officer with regards to DS0000010810.V333413.R01.S.doc 15/06/07 29/06/07 31/08/07 15/06/07 15/06/07 Greenfield Road 9 Version 5.2 Page 28 15. YA42 13(4) water supply (Water Fittings) Regulations 1999 fire doors being propped open. (Previous timescales of 28/02/06 and 30/05/06 not met) The registered person must 29/06/07 ensure that the home’s water supply is test for Legionella and evidence of this must be provided to the local CSCI area office. (Previous timescale of 30/06/06 not met). 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 YA1 Good Practice Recommendations It is recommended that the registered person should ensure that the Statement of Purpose and service user guide are user friendly and a selling tool for the home and the organisation. Copies of these documents should be sent to the CSCI. It is recommended that the registered person should consider organising training for all care staff in ‘person centred planning’ to encourage further involvement by people living at the home and a more holistic approach. It is recommended that a summary of each resident’s individual finance arrangements be recorded on their care plan for clarity, to ensure that they are fully protected. It is recommended that residents be supported to have an annual holiday away from the home as indicated by their expressed wishes. It is recommended that more fresh vegetables be available in the home to ensure a nutritious diet for residents. It is recommended that a computer be provided in the home with internet access, for more efficient running of the home on behalf of residents. It is recommended that an air dryer machine be provided in bathrooms/toilets if paper towels are not suitable for residents, to ensure hygienic procedures within the home. 2. YA7 3. 4. 5. 6. 7. YA7 YA14 YA17 YA24 YA27 Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 29 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 Greenfield Road 9 DS0000010810.V333413.R01.S.doc Version 5.2 Page 30 - 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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