Inspection on 12/10/06 for Marriott Road 18

This inspection was carried out on 12th October 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Marriott Road 18 20/09/05

Marriott Road 18 28/04/05

Marriott Road 18 05/10/04

Marriott Road 18 05/05/04

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 Marriott Road 18 Barnet Hertfordshire EN5 4NJ Lead Inspector Tom McKervey Key Unannounced Inspection 12 & 23rd October 2006 09:30 th Marriott Road 18 DS0000010529.V310745.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 Marriott Road 18 DS0000010529.V310745.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. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Marriott Road 18 Address Barnet Hertfordshire EN5 4NJ 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 8449 9493 020 8449 9493 Hoffmann Foundation for Autism Mr Delroy Gordon Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2005 Brief Description of the Service: Marriott Road is a care home registered to provide care and support for six younger adults who have a learning disability, and who also have autism. The Hoffman Foundation for Autism is a registered charity and manages this home, and other similar homes in the U.K. The home opened in 1989. The property comprises a three-storey townhouse, situated in a pleasant residential area of High Barnet. It is close to shops and leisure amenities and there are good public transport links. There are three bedrooms on the first and three on the second floor. The manager’s office is also located on the first floor. The kitchen/diner, laundry and office for staff, are located on the ground floor, and there is an attractive garden to the rear of the property. The fees for the service are £5200 per person per month. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, which took place over a period of two days, was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The registered manager was at the head office conducting staff interviews on the first day of the inspection. In order to examine the confidential records, the inspector arranged to return for a second day when the manager was present in the home. At the time of the inspection, there were six service users living at the home and there were no vacancies. The inspection process included a tour of the premises, including residents’ communal areas and bedrooms. Care records and staff files were examined, and two staff were interviewed. All the residents were present at the start of the inspection, but five residents left to attend their various day centres. The other resident also went out for a planned activity, supported by a one-to-one care worker. What the service does well: What has improved since the last inspection? Three bedrooms have been redecorated. Criminal Records Bureau clearance has been obtained for a member of staff. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 6 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. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 4 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home meets the needs and aspirations of the residents and their representatives. The residents and their representatives are able to visit the home and they have good information about the service to enable them to make informed decisions about moving in to the home. EVIDENCE: The Statement of Purpose and Service Users Guide provide comprehensive information about the service. The documents are written in appropriate, easy to understand language. No new service users had been admitted since the last inspection. The residents’ files contained detailed information for staff about how to communicate with residents who were non-verbal. This included Makaton, and interpretation of behaviour and gestures. This information is used to enable understanding of the individual resident’s wishes. Residents’ case records showed that they and their relatives had visited the home prior to moving in. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Person-centred care plans provide clear guidance about how best to meet residents’ needs. Staff are trained and experienced to support residents who are non-verbal to make decisions about their lives. Confidential information about the residents is securely stored. EVIDENCE: Three residents’ care plans were examined. The staff have adopted a personcentred approach to care planning. The plans showed that assessments had been carried out of the residents’ needs and the objectives of care, with appropriate actions to meet needs were identified. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 10 The care plans are being reviewed six-monthly. This includes the key worker meeting with staff at the resident’s day centre to review their progress. There were also records of annual reviews by care managers with the resident and their relatives usually present. Residents’ daily records support the care plans, and the residents’ activities were recorded. Appropriate risk assessments were documented regarding activities within the home and in the community. Most of the residents are non-verbal. However, there are very good guidelines for staff about how to ascertain and understand residents’ wishes. Relatives provided much of this information at the time of admission. In addition, staff are also trained to communicate with the residents by interpreting their gestures and through objectives of reference. The staff also use Makaton sign language. Residents’ files and other important documents were stored securely, and the home has a policy about confidentiality. The staff who were spoken to were knowledgeable about the need for confidentiality about residents. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, & 17 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff support the residents in a wide range of activities and to fully access local amenities and facilities. This develops residents’ potential and enables them to have a good quality of life. There is a good variety of well-balanced meals provided. EVIDENCE: Each resident has an activity programme individually tailored to their needs, likes and dislikes. For example, “E is to be supported privately in his room for sensory sessions”. There is an activities room in the home that is used for games and music sessions. A music therapist provides a session once a fortnight. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 12 Five of the residents attend a day centre or college, where groups are run for people who are non-verbal, and one resident receives funding to enable them to have a care worker for one-to-one community-based activities. This includes going to a centre where music sessions are provided. This person also uses public transport when going to activities. Residents spend significant time in the community, for example, going to restaurants, the cinema and areas of interest. Some residents also spend weekends at home with their families. Residents’ activities are documented in their daily records. All the residents had a holiday this year, including venues such as Greece, Scotland and Cornwall. The manager stated that it is not feasible to hold meetings with residents because of their limited ability, but relatives play a significant role in representing residents through three-monthly “Friends of Marriott Road” meetings, which he manager attends. The menus showed that there is a variety of well-balanced meals provided and fresh fruit was available. There was a record of the food actually eaten by the residents to ensure that they ate nutritious meals. A resident was on a reducing diet and their weight was being monitored. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staff are sensitive to how residents prefer support in their personal care. The health needs of the residents are being met from a range of healthcare professionals. Medication is administered safely. The wishes of residents in the event of their death is recorded. EVIDENCE: There are three female and three male residents living at the home. The staff rotas show that there is always male and female staff on duty. There was guidance in individual residents’ records about how they preferred staff to support them in their personal care. For example, “A.. prefers to have a bath at a time when he wants to”. The home is equipped with baths and showers to reflect residents’ choice. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 14 There were records of a wide range of health appointments for residents at the G.P, consultant psychiatrist, dentists and opticians. All residents are weighed monthly and one person was on a weight reducing diet and a walking regime on the advice of the dietician. The accident book showed that accidents/incidents were properly recorded and were up to date. The records for the administration of medicines were examined and there were no gaps. Medication was stored securely and returns of unused medication were documented and signed for by the pharmacist. Staff had received training in the administration of medicines. There is a record in residents’ files of their funeral arrangements in the event of their death. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 15 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 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are good systems in place to ensure the safety and welfare of residents, and staff are trained in adult protection issues. EVIDENCE: The complaint log showed one complaint since the last inspection, which was from a neighbour complaining about noise from a resident’s bedroom. The manager dealt this with satisfactorily. There were records of staff attending training on adult protection. In discussion with staff, the inspector was satisfied that they were knowledgeable about the procedures regarding raising concerns about abuse. Since the inspection, an issue concerning potential abuse of a resident was reported anonymously to the Hoffman Foundation’s management board. The home manager informed the Commission about this matter and he had also informed Social Services. An adult protection strategy meeting had not yet been held at the time of writing this report, However, the inspector was satisfied that appropriate actions had been taken. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 16 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, 25 & 30 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of décor and maintenance of the building is good and provides a safe environment for residents and staff. The residents’ bedrooms are attractive and comfortable and reflect their individual interests and preferences. However, in one specific instance, steps need to be taken regarding covering a bedroom window to protect the resident’s privacy and dignity. The home is clean and tidy, but pedal bins have to be provided in toilets and bathrooms to improve hygiene and minimise the risk of infection. EVIDENCE: An inspection of the premises was carried out. The exterior of the building was in good condition and the garden was well maintained. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 17 Since the last inspection, three bedrooms had been redecorated and at the time of the inspection, the manager was obtaining quotes for the refurbishment of a bathroom and the main lounge. Four bedrooms were inspected. In one bedroom, there was no curtain on the window. The manager said that this particular resident kept pulling the curtain off the rail. While this problem is acknowledged, it is not acceptable for this resident’s privacy to be compromised and other means should be used to meet the resident’s needs in this regard. For example, Velcro or shaded glass. A requirement is made to address this matter. They were in good decorative order and the furnishings were appropriate and in good condition. All the bedrooms had individual colour schemes and had personal items of furniture and equipment, for example; televisions, music systems and pictures and posters. There is a cleaner employed in the home, and at the time of the inspection the home was very clean and tidy and there were no offensive odours. However, the waste bins did not have lids. This could pose a risk of infection, and a requirement is made to provide pedal bins in toilets and bathrooms. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 18 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): All these standards were examined. The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are cared for by a group of staff that is well trained and knowledgeable about their roles. There are good procedures for screening new staff, but more care must be taken to obtain a satisfactory explanation when there are gaps in their employment histories. This is necessary to protect the welfare and interests of the residents. Staff receive regular supervision to support them in their role as carers. EVIDENCE: Two members of staff were spoken to, independently. They demonstrated a thorough knowledge of the residents and their needs, and described their areas of responsibility for providing care and support. Four staff, (50 ) of the care staff, have attained National Vocational Qualification level 2 and all new staff undergo a written induction when they commence employment at the home. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 19 In addition, each member of staff undergoes a training programme tailored to the needs of the residents. This includes mandatory health and safety subjects, autism, challenging behaviour and epilepsy. The staff rotas showed that there were sufficient numbers staff on duty at all times to meet residents’ needs. One resident has funding for one-to –one support. The records of two new staff were examined. Criminal Records Bureau checks had been obtained and references. However, it was noted that there was no explanation for gaps in employment histories and a requirement is made about this issue. There is a three-month probationary period for new staff and all staff have an annual appraisal. Staff confirmed that they received regular supervision from their line managers, which they valued. They said; “Supervision gives us an opportunity to discuss issues in confidence, and lets me know how well I’m doing”. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 20 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, 38, 39, 40, 41 & 42 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager is appropriately qualified and experienced and there is a good team spirit among the staff, which enables a good quality of service for residents. The residents’ welfare and best interests are safeguarded by appropriate policies and procedures and good record keeping. Generally there are good monitoring systems in place for ensuring the health and safety of residents and staff, but the water supply to the home must be tested to exclude the presence of Legionella. EVIDENCE: The manager has attained the Registered Manager’s Award and NVQ Level 4 qualification, and is registered by the Commission for Social Care Inspection. He is supported by a deputy manager. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 21 Staff who were spoken to, described the manager’s style as, “Patient and effective”. They also said that the morale among the team was very good and they thoroughly enjoyed their jobs. One resident’s cash tin was checked at random. The amount of cash balanced with the recorded amount. Receipts had been kept for all purchases made on behalf of the resident. Reports of monthly inspections of the home by senior managers are sent to the Commission for Social Care Inspection, and an annual audit of the service had also been carried out this year. This audit included the views of service users’ representatives. The manager said that it was not possible to hold meetings with the residents because of the nature of their disabilities. However, regular meetings are held with their relatives at which they are able to have an input into the running of the home. Minutes of these meetings were available for inspection. Residents’ case files and documents pertaining to the management of the home were well structured and available for inspection. There were records of health and safety audits and COSHH materials were stored securely. The fire logs showed that alarm tests and drills were conducted regularly, and the temperatures of the fridge and freezer were recorded daily. Certificates of safety were seen for fire, gas and electrical installations and there was a current employers liability insurance certificate on display. It was noted that the water storage system had not been tested for Legionella in the past year and a requirement is made to address this issue. Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 22 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 X 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 3 2 X Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 23 No 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 YA25 Regulation 16(2)(c) Timescale for action The registered person must 30/11/06 provide appropriate cover for a specific resident’s bedroom window to safeguard their privacy and dignity. The registered person must 31/12/06 provide pedal bins in toilets and bathrooms. The Registered Person must 30/11/06 ensure that there are satisfactory explanations for gaps in the employment histories of newly recruited staff. Requirement 2. 3. YA30 YA34 13(3) 7,9,19 Sch 2 & 4 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 24 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 Marriott Road 18 DS0000010529.V310745.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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