Inspection on 07/02/06 for Kitchener Road 83

This inspection was carried out on 7th February 2006.

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

The inspector found 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kitchener Road 83 16/01/07

Kitchener Road 83 26/07/05

Kitchener Road 83 08/11/04

Kitchener Road 83 19/07/04

Kitchener Road 83 23/02/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Kitchener Road 83 London N17 6DU Lead Inspector Caroline Mitchell Unannounced Inspection 7th February 2006 09:00 Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 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 Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 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. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Kitchener Road 83 Address London N17 6DU 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 8808 6931 Mr Edward William Marcus Beverley Delano Willis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: 83 Kitchener Road is a privately run home for adults (aged 18-65) who have a learning disability. The home is an ordinary house, similar to its neighbours in a residential area of Tottenham north London. The stated aims of the home is to provide care to people who have a learning disability (usually mild to moderate) or service users with an autistic spectrum disorder including some users who may have complex behavioural problems. Priority is given to maintaining privacy, dignity, independence, security, civil rights, choice and fulfilment. Accommodation in the home is provided in three single rooms, one on the ground floor (with an en-suite shower and toilet facility) and two on the first floor (each equipped with a hand basin and sharing a bathroom and two toilets nearby). A sleeping in room and office are also provided on the first floor. Service users also have access to a lounge area, diner/conservatory, and rear garden area. Service users resident in the home are supported to use nearby community facilities to meet education and recreational needs including local transport networks, leisure facilities and shops in close proximity to the home. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis. The inspection took around two hours to complete. The inspector was shown around the house and reviewed a number of the records kept in the home. The inspector spoke with the acting manager and also had the opportunity to meet some staff members and to speak briefly with two service users. What the service does well: 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. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 6 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 Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Service users’ needs are assessed prior to them moving to the home. They are able to visit the home and have overnight stays prior to making the decision to move in. EVIDENCE: One service user had moved into the home only two weeks prior to the inspection and the inspector reviewed the written records for this service user. They showed that a full assessment had been provided to the home prior to the service user’s admission so that the home was clear about the service user’s needs. The service user had visited the home on numerous occasions, had overnight stays and the staff from the home had visited him in his previous placement, prior to his moving in. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, & 9 In order to best serve service users’ interests service user plans and risk assessments are in need of being further developed. EVIDENCE: Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 9 One service user has a “communication passport” which is a book kept by the service user that sets out the ways in which he communicates, his likes and dislikes, interests, activities, and other information that is helpful in understanding his life. It is pictorial and of a high standard, being service user focussed and service user led. The acting manager showed the inspector a copy of an “individual support plan”, a detailed in- house plan that she was completing for another service user, and said that the intention is to provide each service user with an “individual support plan”. As the support plan and the communication passport are of a high standard a recommendation is made that they are put in place for each service user. One service user moved into the home only two weeks prior to this inspection and the inspector reviewed his written records. There is a plan in place, which was completed by the placing authority in preparation for his admission to the home. Detailed risk assessment was also available as part of the assessments undertaken prior to service user’s admission. No in-house plan or risk assessment had yet been formulated and the acting manager explained that an plan and risk assessments are to be created, as the service user settles in and the staff get to know him, and that a “communication passport” will also be devised. Requirements are made in respect of this. The acting manager showed the inspector a copy of an “individual support plan”, a detailed in- house plan that she was completing for another service user, and said that the intention is to provide each service user with an “individual support plan” and a “communication passport”. As these are of a very high standard and provide The registered provider is the appointee for the service users. At the previous inspection a requirement was made for service users’ money to be paid into accounts in their names rather than to the business account of the home, and the inspector was able to confirm that this issues was being addressed appropriately. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, & 17 The daily routines in the house do generally promote independence, individual choice and freedom of movement. There are some restrictions placed on service users, and these are for their own safety, and are documented appropriately. The service users are provided with a rich and varied social life by the home with range of, appropriate leisure activities being offered. Staff support service users to participate in activities, the local community and service users do maintain family links and friendships. EVIDENCE: Service users are encouraged to be involved in the tasks of daily living e.g. making their own breakfasts and tidying their rooms. The service user plans detail support to be provided in order to maintain and develop social, emotional, communication and independent living skills as part of weekly timetables. The same service provider also provides community based day activities for the service users. Comprehensive weekly plans of activities were available for each of them. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 11 Local leisure facilities such as the cinema, swimming pool, snooker halls and pubs are also visited frequently. One service user attends a local church another visits a number of Turkish cafes in the local area on a regular basis, and all service users enjoy visiting their family members regularly. Records reflected that service users went out for meals, for long walks, swimming, bowling, and shopping and to the cinema. Within the home, Greek and Turkish TV channels are installed on the televisions. One service user goes out independently, visiting arcades, cafes and shopping areas. The most recently admitted service user is from an Afro-Caribbean background and the acting manager explained that a particular staff member is assigned the task of finding out more about the food that the service user likes and dishes that reflects his cultural background, so that these can be provided as part of the menu. Further advice is also being sought from a dietician regarding his particular dietary needs. A requirement is made in relation to adjusting the menu to take into account the needs and preferences of this service user. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 The healthcare needs of service users are assessed and recognised and that procedures are in place to address them. The service users are protected by the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. Service users can be confident that the home would deal with the ageing, illness and death of a service user with sensitivity and respect. EVIDENCE: Service users are registered with different local GPs and examination of service users’ records showed that they were supported to access medical practitioners including the optician and dentist as required. The home is also able to access specialist medical support from the learning disabilities team based at the nearby St. Anne’s hospital. The home uses the Boots medication system. There was evidence that staff members had attended appropriate training courses in the administration of medication. A video on the correct administration of medication is available in the home. Inspection of the medical administration records indicated that medication was being administered and recorded accurately. There was evidence that the temperature at which medication is stored was being monitored and recorded on a daily basis. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 That there are clear and effective complaints, adult protection and whistle blowing procedures and service users are safeguarded from abuse and neglect. EVIDENCE: The complaints procedure is clearly written, included clear time scales for the process, and informs complainants that they may contact the Commission for Social Care Inspection at any stage of the process should they wish, as required. The complaints procedure is available in Greek for one service user currently accommodated. No complaints had been recorded since the previous inspection. The registered person has produced an adult protection procedure (including whistle blowing), and had obtained a copy of the local authority’s adult protection policy. There was evidence that staff members had attended training in adult protection and the prevention of abuse. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27 & 30 The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; and meet service users’ individual and collective needs in a comfortable and homely way. Service users’ bedrooms are furnished nicely and meet individual needs and lifestyles. The home provides service users with toilet and bathroom facilities. The premises are kept clean, hygienic and free from offensive odours throughout. EVIDENCE: The home is an ordinary house in keeping with the local community. The premises are comfortable, bright, and cheerful and there is sufficient and suitable light in each room. Furnishings and fittings in the home are of good quality, and domestic in character. The communal space in the lounge and dining room comfortably exceeds the national minimum standards in terms of space. The front and rear gardens are well maintained. At the previous inspection the registered provider was required to ensure that the paintwork on the exterior of the home be attended to in places where it is beginning to wear. At this inspection the inspector was able to confirm that this had been done. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 15 Each service user has their own, private single bedroom. All bedrooms have sufficient and comfortable furniture and were decorated and equipped to reflect the backgrounds and interests of their occupants. The home provides a total of two toilets, a bathroom and a shower in addition to the en suite facilities located in the ground floor bedroom. The toilet and bathroom areas are clean, well maintained and provide facilities appropriate for the needs of the service users currently resident in the home. An inspection of the house showed that it was well maintained and cleaned to a good standard. Laundry facilities are sited in the conservatory area and do not affect the operation of the kitchen. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 The home operates a reasonably robust recruitment procedure. However, there is a still a need for some further work to ensure that service users are more fully protected. The home has an effective staff team with sufficient numbers and complementary skills to meet service users’ needs. EVIDENCE: The inspector saw the staff records for five staff, two of whom had been recently recruited. Whilst the records regarding staff members were of reasonable quality. However, there is still some room for improvement. The application form for staff, whilst of a good quality, does not currently provide as full an employment history of applicants as is necessary. As previously stated, applicants must provide an explanation of any gaps in their service. The inspector found that this issue had not been satisfactorily addressed and the requirement is restated and revised to include revision of the current application form to ensure that a full work history is provided by applicants. At the previous inspection some files did not include a recent photograph of the staff member. The inspector noted that there was evidence that this had been addressed for the staff files seen at the time of the previous inspection. However, some files did not include photographs, and these were files for staff who had been recruited very recently. This requirement is restated. Previously a requirement was made for the registered person to ensure that for workers from overseas, records include sufficient evidence of their right to Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 17 work in this country along with the date each staff member started work in the home. The inspector was able to confirm that these requirements had been satisfactorily addressed. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 42 The home does not have a registered manager at present. However, there is an acting up arrangement and the staff team are trying to ensure that this does not adversely affect the service users. EVIDENCE: As the registered manager of the home is unable to work due to ill health the registered person has put in place an acting up arrangement to manage the home on a day-to-day basis. Until the issue is resolved senior staff member is temporarily acting as manager until a permanent manager can be recruited. Although she is doing a reasonable job of running the home on a day-to-day basis, the home would benefit from the recruitment of a permanent and experienced manager. Although good records are kept of regular fire drills, at the last inspection a requirement was made for the registered person to ensure that individual service users risk assessments address the issue of their safe removal from the home in the event of a fire. At this inspection thE inspector was able to confirm that this issue hade been satisfactorily addressed. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Kitchener Road 83 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000031156.V271803.R01.S.doc Version 5.0 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19, 17 Sch 2 & 4 Requirement The registered person must ensure that all applicants provide an explanation of why they left each post, where previously employed with children or vulnerable adults. It is also necessary to ensure that applicants provide a written explanation of any gaps in their service. The previous timescale of 30/11/05 was not met. 2 YA34 19, 17 Sch 2 & 4 30/04/06 The registered person must ensure that a recent photograph of each staff member is included in the individual personnel records of all staff working in the home. 30/04/06 The registered person must ensure that the relevant risk assessments are in place for each service user. Timescale for action 30/04/06 3 YA9 13 (4) Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 21 4 YA6 15 The registered person must ensure that a service user plan (individual support plan) is in place for each service user. 30/04/06 5 YA17 12(4) (b) The registered person must ensure that the menu is adjusted to take into account the needs and preferences of one service user, who was most recently admitted to the home. 30/04/06 6 YA37 38, 39 The registered provider ensure that a permanent manager with sufficient experience is recruited to manage the home and that an application is submitted for the manager to be registered by the Commission. 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is recommended that an “individual support plan” and a “communication passport” are put in place for each service user in the home. Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kitchener Road 83 DS0000031156.V271803.R01.S.doc Version 5.0 Page 23 - 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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