Inspection on 20/09/05 for Marriott Road 18

This inspection was carried out on 20th September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Marriott Road 18 12/10/06

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 Unannounced Inspection 20th September 2005 10:55 Marriott Road 18 DS0000010529.V249367.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 Marriott Road 18 DS0000010529.V249367.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. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 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.V249367.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 Brief Description of the Service: Marriot 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, which is a registered charity, manages this home and other similar homes in the UK. 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 second floor. The kitchen/diner is located on the ground floor, and there is an attractive garden to the rear of the property. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over a period of four hours. The purpose of the inspection was to determine what progress had been made since the last time the service was inspected, and to identify any shortfalls. The registered manager was present throughout the inspection and fully cooperated with the process. 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 service users’ communal areas and bedrooms. Care records were examined and staff were interviewed. Five residents were away from the home at various day centres. One other resident was present, but later went out for a planned activity, supported by a one-to-one care worker. The staff, who were spoken to independently, were knowledgeable about the residents, and they said that their morale was very good. What the service does well: What has improved since the last inspection? The manager is now registered with the Commission for Social Care Inspection. The administration of medicines has improved so that all Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 6 medication is signed for. An audit of the quality of the service has been carried out. The décor in a resident’s bedroom has been improved and a new bed and pictures have been purchased. The floor of the laundry has been recovered to prevent leakages, and a new fridge has been purchased. 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.V249367.R01.S.doc Version 5.0 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.V249367.R01.S.doc Version 5.0 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 The residents and their representatives are provided with comprehensive information about the service, which enables them to make informed decisions about moving in to the home. The home meets the needs and aspirations of the residents and their representatives. 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 gave 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. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 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, 9 & 10 Staff have clear guidance about how best to meet residents’ needs through good care planning, and information about the residents is securely stored. EVIDENCE: Two residents’ care plans were examined. They contained assessments and objectives of care, with appropriate actions to meet objectives. The care plans had been reviewed six-monthly. However, the outcome of these reviews was not recorded. A recommendation is made to include a column in the new care plan format, for recording the outcome of the evaluation. There were records of annual reviews by care managers with the service user and their relatives usually present. Good daily records support the care plans, and reflect residents’ activities. Appropriate assessments were recorded for residents regarding activities within the home and in the community. Residents’ files and other important documents were stored securely, and the home has a policy about confidentiality. Marriott Road 18 DS0000010529.V249367.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, 15 & 17 Residents are well supported to integrate with the local community, which develops their potential and enables them to have a good quality of life. Residents have ample, nutritious food to eat. 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”. 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, which enables them to have a care worker for one-to-one activities. At the time of the inspection, a resident was attending an enrolment assessment at a college. Records indicated that residents spend significant time in the community, going to restaurants, the cinema and areas of interest. Some residents also spent weekends at home with their families. The registered manager stated that relatives play a significant role in representing service users, through three-monthly “Friends of Marriot Road” Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 11 meetings, the minutes of which were seen. The manager attends these meetings, which are held in the relatives’ homes. The group also raises funds for amenities for the home. The menus showed that varied and well-balanced meals were provided. Fresh fruit was available. One resident was on a reducing diet and their weight was being monitored. There was a record of the food actually eaten by the residents to ensure that they ate nutritious meals. Marriott Road 18 DS0000010529.V249367.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): 18, 19 & 20 The health needs of service users are being met from a range of healthcare professionals, and there is a safe system in place for the administration of medicines. EVIDENCE: The staff rotas show that there is always male and female care staff on duty to attend to the residents’ personal care. The case records detailed the health appointments attended by service users at G.Ps, consultants, dentists and opticians. The accident book showed that accident/incidents were properly recorded and were up to date. The records of administration of medicines and the procedure was found to be safe. Marriott Road 18 DS0000010529.V249367.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 There are good systems in place to ensure the safety and welfare of residents, and staff are trained in adult protection issues. EVIDENCE: The last recorded complaint was in September 2004. There was a history of complaints from the next-door neighbours who were concerned about excess noise from a resident’s room. The manager stated that a quote had been obtained to soundproof the room and funding for this had been applied for. There were records to show that staff had received training in adult protection procedures. A member of staff who was spoken to, was aware of their responsibilities regarding abuse issues and was able to describe appropriate actions to take if there were any concerns. The inspector checked the records of one resident’s personal money. The amount of cash balanced with the records, and receipts of purchases were also available. Marriott Road 18 DS0000010529.V249367.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, 25, 26 & 30 There have been continuous improvements to the building and the décor of the home. This has resulted in a safer and more attractive environment for residents and staff. There are good standards of cleanliness and hygiene for the comfort and protection of the residents. EVIDENCE: Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 15 The building is owned and maintained by the local authority. An inspection of the premises was carried out. The home appeared to be well maintained, with evidence of recent redecoration being carried out. The laundry had a new floor and a bedroom had been redecorated. There was a new swing hammock in the garden, (purchased by the relatives), and a new fridge had been ordered on the day of the inspection. Each bedroom was visited. They were in good decorative order and the furnishings were appropriate and in good condition. All bedrooms have laminated flooring. One particular bedroom had been rearranged to so that the resident had easy access to their music system and c/d’s. The manager said that this had significantly reduced this resident’s challenging behaviour. There is a cleaner employed and at the time of the inspection, the home was very clean and tidy and there were no offensive odours. Marriott Road 18 DS0000010529.V249367.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): 31, 33 34 & 36 Residents are cared for by a group of staff who are well supervised, knowledgeable and caring. However, there are still problems in ensuring that all staff are appropriately screened to avoid the risk of residents being put at risk of abuse. EVIDENCE: Staff who were spoken to, demonstrated a thorough knowledge of the residents and their responsibility of care. The staff rotas showed that there were sufficient numbers staff on duty at all times to meet residents’ needs. One service user has funding for one-to –one support. A member of staff still did not have a Criminal Records Bureau check, despite a requirement about this matter being made at the last inspection. The manager said that he had not received the appropriate application form this person, even after several reminders. A requirement is restated, that this staff is not employed at the home until a satisfactory Criminal Records Bureau clearance is obtained. Staff confirmed that they received regular supervision from the line managers. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 17 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 & 42 The manager gives good direction and leadership, and there is good morale among the staff team, which enables a good quality of service for residents. EVIDENCE: The manager has attained the Registered Manager’s Award and NVQ Level 4 qualification, and has recently been registered by the Commission for Social Care Inspection. A member of staff who was spoken to, said that the home always had “good managers” and described the morale among the staff as very good, for example; “ I have never worked anywhere as good as Marriot Road. The work practices are very good and the staff team is very professional”. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 18 Reports of monthly inspections of the home by senior managers, monitoring the quality of the service, are sent to the Commission for Social Care Inspection, and an annual audit of the service had also been carried out. 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. Marriott Road 18 DS0000010529.V249367.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 3 X 3 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 4 3 X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Marriott Road 18 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X 3 X DS0000010529.V249367.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 34 Regulation 7, 9 & 19 Sch 2 & 4 Requirement The registered person must ensure that a member of staff is not employed at the home until a satisfactory Criminal Records Bureau clearance is obtained. Timescale for action 30/09/05 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 6 Good Practice Recommendations The registered person should ensure that staff record the outcome of the review of care plans. Marriott Road 18 DS0000010529.V249367.R01.S.doc Version 5.0 Page 21 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.V249367.R01.S.doc Version 5.0 Page 22 - 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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