Inspection on 04/04/06 for Matthew Residential Care Limited

This inspection was carried out on 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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 Matthew Residential Care Limited 59 Woodgrange Avenue Kenton Harrow Middlesex HA3 0XG Lead Inspector Julie Schofield Key Unannounced Inspection 4th May 2006 08:30 Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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 Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Matthew Residential Care Limited Address 59 Woodgrange Avenue Kenton Harrow Middlesex HA3 0XG 020 8907 8435 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) Matthew Residential Care Limited Ms Catherine Lewis Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary variation agreed for one named individual JH service user mental health category for the duration of his stay (as agreed 27th May 2004). 26th September 2005 Date of last inspection Brief Description of the Service: 59 Woodgrange Avenue is situated in a turning off Kenton Road and is a short walk away from local shops and bus routes. The property accommodates 3 residents with learning disabilities and at the time of the inspection there were no vacancies. There is a spacious lounge and a separate dining room on the ground floor and a kitchen. In addition there is also a shower room, with basin and toilet. On the first floor there are 3 single bedrooms, each with a wash hand basin. There is a bathroom with a wash hand basin and bath and there is a separate toilet. There is a room on the first floor, which is used for some storage of records, staff sleeping in facilities and as the laundry room. There is an office in the garden, adjacent to the house. The area of the front of the property has been paved to provide off street parking and there is an attractive garden at the rear of the property. Information regarding the level of fees charged is available, on request, from the manager of the home. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday in May 2006. It consisted of 2 visits, on the same day. The first visit began at 8.30 am and finished at approximately 12 noon. The second visit began at 3.15 pm and finished at 6.50 pm. The Inspector would like to thank the manager, deputy manager and carer for their assistance during the inspection. During the inspection discussions with the manager and staff took place, records were examined, the preparation of a meal was seen and a site visit was carried out. The Inspector spoke with each of the 3 residents and would like to thank them for their comments. What the service does well: What has improved since the last inspection? Eleven statutory requirements had been identified during the previous inspection. There is now compliance with each of the statutory requirements identified. Residents are offered a copy of their care plan and review meetings are held at least on a 6 monthly basis. Day care programmes are drawn up and put into action. Residents are consulted on a regular basis about activities Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 6 they may wish to enjoy, both inside and outside the home. The Inspector was given access to the home. Staff administering medication have received training and have recorded the administration after the task has been carried out. Paintwork on the window frames has been made good and repainted, the weeds growing between the paving stones have been removed and a new set of dining chairs has been purchased. The 50 target for trained carers has been reached (and exceeded). Staff have received food hygiene training and the information about the safe use of products kept in the COSHH cupboard is available to staff. Since the last inspection improvements to the property have taken place. The home has been recarpeted. The garage in the garden at the rear of the property, which adjoins the house, has been converted into an office. This room is more spacious than the previous office, which was on the first floor of the house, as it does not accommodate the laundry facilities or the sleeping in facilities. What they could do better: Risk assessments must be drawn up for when residents use the kitchen and for when they take an annual holiday. Records need to be up to date and complete for the core temperature of food e.g. roast meat that is served in the home. The storage of food in the freezer and in cupboards must include the securing of bags once they have been opened. The paper towel dispenser in the kitchen must be kept stocked. The date on which the CRB disclosure is returned to the home must be recorded so that the validity can be checked. Quality assurance systems need to be in place for collecting written feedback in respect of the service provided in the home. It is recommended that the names of persons attending review meetings are recorded, that a risk assessment is drawn up for the non-provision of a television, that a health action plan is drawn up for the last resident to be admitted to the home, that the Christmas cards are removed from the lounge, that the training and development plan is reviewed on an annual basis and that the computer cable is removed from the entrance hall. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 7 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. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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 Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the standards were inspected during this inspection as no new resident has been admitted to the home since the previous inspection in September 2005. EVIDENCE: Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 10 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 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. The home is able to demonstrate that changes in the needs of residents are identified and addressed through a system of regular review meetings. The resident’s right to make decisions about their life in the home is respected. Responsible risk taking contributes towards the resident leading an independent lifestyle and reviewing these on a regular basis ensures that the changing needs of residents are identified and addressed. However risk assessments are needed for some additional activities. EVIDENCE: Care plans were inspected. They identified social, personal and health care needs. Within each need, potential hazards were identified. Care plans were signed and dated and the resident also signed the care plan. A statutory requirement was identified during the previous inspection that residents are Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 11 given a copy of their care plan. Although this has been done the manager said that they have found that the residents have discarded them. A statutory requirement was identified during the previous inspection that review meetings (internal or external) are held on a regular basis i.e. at least every 6 months. It was noted from the visitors’ book that a reviewing officer from the placing authority had visited each resident recently. Case files included evidence of 2 reviews of the care plans being held in 2005. The minutes of the internal review meeting did not include a list of persons attending. The home has a system of key working and residents were able to name their key worker. Residents gave examples of their right to make decisions and these included when they got up in the morning and when they went to bed, what they ate, what activities they took part, where they went on holiday, what clothes they wore, how they spent their money, whether they wanted to socialise in the home or enjoy the privacy of their own room and how they spent their time. Information about an advocacy scheme run by Harrow Mencap was on display in the home. Residents receive benefits directly. They may request assistance in withdrawing money from their account, budgeting or saving for a holiday etc. Those receiving assistance have a record book and these were available for inspection. Records were up to date and complete and included details of any money held in savings accounts. Risk assessments were tailored to the individual needs of residents. They included maintaining privacy in the bedroom, dealing with anxieties, personal care etc. The risk assessment included pro-active intervention. There was evidence that risk assessments had been reviewed. Risk assessments had not been recorded for residents taking part in an annual holiday or using the kitchen. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 12 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): 12, 13, 14, 15, 16, 17 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. Residents are encouraged to maintain contact with their families, to establish relationships and to observe their religious practices so that their social and spiritual needs are met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Residents are offered a balanced diet to promote their well being and the diet respects their religious and cultural needs. However the storage and preparation of food must adhere to good food handling practices in order to maintain its wholesome state for residents. EVIDENCE: A statutory requirement was identified during the previous inspection that day care programmes are drawn up for each resident and are put into practice. This was in respect of a resident who chose not to go to a day centre and a programme has been agreed with the resident. Activities have been arranged Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 13 both inside and outside the home including artwork, pottery, cooking, shopping trips etc. The resident confirmed that she is satisfied with the programme that has been drawn up. One of the other residents attends a day centre on 3 days per week and a computer centre on 2 days per week. The third resident attends a day centre on 3 days per week and said that she enjoys relaxing at home on the other days. One of the residents attends the Temple, which meets his spiritual needs. All of the residents are mobile and use public transport or taxis if they need transport. Two of the residents are able to travel independently and one of them said that the staff had helped them to achieve this. Residents make use of community resources including shops, restaurants, pubs, cinemas, the library, cultural centres and clubs. Although it was polling day on the day of the inspection and residents had received polling cards they said that they did not want to vote. A statutory requirement was identified during the previous inspection that residents are consulted on a regular basis about the activities both inside and outside the home that they wish to take part in. The manager said that as the residents have their own individual interests they prefer not to take part in group activities and there was evidence that residents were able to pursue their own individual interests. One resident has a laptop computer in their room and they enjoy using this and playing their DVD’s (Asian films) through this. Although it is the practice of the home to provide a television in the resident’s bedroom this has not been provided for 1 resident, for health and safety reasons, as they like to open up items to see how they work and to experiment with a screw driver. Residents attend clubs, dances and social events. One of the residents who is Asian attends clubs that meet his cultural and religious needs. Two of the 3 residents went on holiday in 2005 and they said where they wanted to go this year i.e. to Euro Disney. One of these 2 residents said that she was excited about going to Paris because this will be the first time that she has been abroad. The third resident was offered the opportunity of going on a holiday in 2005 but was reluctant to leave the house. The manager is hoping to persuade her to take a holiday in the UK this year. A statutory requirement was identified during the previous inspection that the Inspector is given access to the home by staff, whether the inspection is announced or unannounced. The manager said that all staff have been advised regarding this and on the day of the inspection the Inspector was invited into the home on both of the visits. It was noted that in the visitors book there was a record of relatives visiting residents in the home. Residents are able to entertain their visitors in their room, if they wish. Two residents also visit their families, and 1 resident occasionally stays the night with them, when they wish. Residents confirmed that the privacy of their room is respected and residents are offered a key to their bedroom. Two of the residents chose to use these. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 14 Residents are encouraged to take part in the daily routines of the home although one resident said that they did not enjoy helping with their laundry. Residents are expected to keep their rooms clean and tidy and residents have the opportunity to do some cooking, with supervision, if they wish. The home has a 5-week menu system. The menus were varied and wholesome. Fresh fruit, vegetables and salad were included and there was variety amongst the protein and carbohydrate groups. There is a separate menu of Asian foods, to meet the cultural and religious needs of a Hindu resident and the resident is able to choose an alternative to the main menu, when they wish. Individual food records are kept. The record of the core temperature for meat etc served in the home had not been completed for May. An evening meal was prepared during the inspection and it consisted of chicken, rice, carrots and broccoli. It looked wholesome and the food smelt appetising. The member of staff preparing the meal confirmed that she had undertaken a food hygiene training course. The fridge and freezer were checked. It was noted that in the freezer bags of food had been opened and not securely fastened after use. There was a very large bag of rice in a cupboard which had been opened and which had not been securely fastened after use. The paper towel dispenser above the wash hand basin in the kitchen for staff, and residents, involved in the preparation of food was empty. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive prompting with personal care in a manner, which respects their privacy and dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP EVIDENCE: The staff team consists of both male and of female members of staff so a member of the same sex supports residents with personal care. The support may take the form of prompting or direct assistance. The home has encouraged residents to establish and to maintain good standards of personal hygiene and one resident now enjoys having a regular bath and using perfume. A health action plan was on file for the resident that had lived in the home for a few years but not for the resident who had lived in the home for less than 12 months. There was evidence on file that residents had access to health care services in the community e.g. the optician, the dentist, the chiropodist and the GP. Letters on file confirmed appointments with a psychologist and a Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 16 psychiatrist. They mentioned support by a member of staff or a manager when the resident had an out patient appointment. There was evidence of residents being offered the flu jab. One resident is receiving support to lose weight and their weight is being monitored as the GP instructed. A medication policy and procedure are in place in the home. A statutory requirement was identified during the previous inspection that all staff administering medication are trained to carry out this task. The member of staff on duty confirmed that they had undertaken medication training. The storage of medication was inspected. Medication is stored in a locked facility. There was a record in the cabinet that the pharmacist carried out a 3 monthly audit of the storage and of the recording of the administration of medication. The storage was orderly and medication was stored on separate named shelves within the cabinet. The home does not use a dosette or blister pack system for the administration of medication to residents. A statutory requirement was identified during the previous inspection that staff initial the records of administration immediately after carrying out the task and not before. Records were examined and were up to date and complete. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of their right to complain if the care that they receive is not satisfactory. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: A complaints procedure is in place in the home. The manager said that no complaints have been recorded since the last inspection. Residents said that they were satisfied with the service provided but if there was anything that they were not satisfied with they felt able to speak to someone in the home e.g. Catherine (the manager). As part of the admission procedure the complaints procedure is discussed with the resident. The home has developed a user-friendly format for this purpose. The manager said that the most recent admission to the home declined to have her own copy of the procedure although the resident signed an acknowledgement that this part of the admission procedure had been completed. There is a copy of the complaint’s procedure in the kitchen and the manager said that she encourages residents to give feedback whenever they see her or to discuss matters during the residents’ meetings. Residents are also able to speak to her privately and one resident says, “Catherine, can I have a 1 to 1” when there is something that the resident wishes to discuss. A protection of vulnerable adults procedure is in place. Since the last inspection the home contacted the placing authority on behalf of a resident when the resident made a disclosure of alleged abuse. The allegation did not involve any other resident or member of staff in the home. The home followed Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 18 the correct procedure, in accordance with the interagency guidelines, a copy of which is kept in the home. The member of staff on duty confirmed that they had undertaken protection of vulnerable adults training. They said that a member of the crisis intervention service had also given them training in respect of managing challenging behaviour. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 19 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is comfortably furnished and provides a pleasing environment for residents to relax and enjoy. Residents live in a home where standards of cleanliness are good. EVIDENCE: A site visit took place. A statutory requirement was identified during the previous inspection that the peeling paintwork on the window frames, on the outside of the house, is made good and redecorated, that the weeds are removed from the paved area at the front of the house and that the dining chair is replaced. It was observed noted that the paintwork on the window frames had been made good and repainted, the weeds growing between the paving stones had been removed and a new set of dining chairs had been purchased. The maintenance of the home was good and residents said that they enjoyed their surroundings, which were comfortable. One resident had their own chair in the lounge, which they had purchased, and were pleased that they had been able to bring this with them when they were admitted into Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 20 the home. Residents said that they were pleased with their own private accommodation. It was noted that Christmas cards were still in the lounge. There was a letter on a resident’s file confirming a visit made by the social worker where it was acknowledged that the resident had damaged their wash hand basin when they tried to remove it from the wall and it had been agreed with the home that for health and safety reasons a new basin would not be installed. (The resident is still able to use the wash hand basin in the bathroom or in the shower room). It was noted during the site inspection that the home was clean and tidy and free from offensive odours. Residents said that the home “was always like this”. Laundry facilities are accommodated in a room on the first floor and are suitable for the needs of the 3 residents. Staff have undertaken infection control training. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 21 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): 32, 33, 34, 35 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general skills and knowledge of carers is enhanced by NVQ training and residents benefit from this. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents. A record of the date on which the CRB disclosure is returned is needed to demonstrate that it is valid. An induction training programme is in place for staff to demonstrate that they have the skills and understanding necessary to meet the individual needs of residents. EVIDENCE: A statutory requirement was identified during the previous inspection that 50 of care staff achieve an NVQ level 2 qualification. Of the 4 carers currently employed 2 members of staff have obtained their NVQ level 2 qualification and are currently undertaking level 3 training and the other 2 members of staff have obtained their NVQ level 3 qualification. The home has exceeded the 50 target for carers achieving an NVQ level 2 or 3 qualification and is to be commended. A carer who was on duty confirmed that they had successfully completed their level 2 training and was currently undertaking level 3 training. The carer said that they had also been given training in respect of autism and Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 22 managing challenging behaviour from a member of the Crisis Intervention Service. Staffing levels were reviewed. It was noted that the home was maintaining agreed levels. There are either 1 or 2 staff on duty during the day, (this may include the deputy manager or the manager), and at night one member of staff is asleep, but on call, in the home. Staffing levels are sufficient to enable residents to be supported by staff, both inside and outside the home. Details of the on call management rota were on display in the kitchen. Two staff files were examined. Both files contained an application form, proof of identity, 2 references, evidence that an enhanced CRB disclosure had been obtained (but not the date on which it was returned to the home), a work permit where one was necessary, a job description and a statement of terms and conditions. Two staff files were examined. The home offers a basic induction to the house, the residents, care practices and an introduction to the policies and procedures. An induction training booklet is used to record the progress made by the member of staff. The home has a system of training profiles, which list all the courses that the member of staff has attended. It was agreed during the process of applying for a variation to the conditions of registration of the home for the admission of a resident with learning disabilities and mental health problems that staff would receive mental health training and this took place. Each of the 2 members of staff had received training in safe working practice topics, medication and protection of vulnerable adults procedures as part of their induction and foundation training. The training and development plan for the home was drawn up previously and has not been updated. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 23 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, 39 42 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager continues to develop her knowledge through further training and this contributes towards understanding the needs of residents and staff. Service satisfaction questionnaires help to monitor the quality of the service provided to residents and contribute towards the development of the service and the home needs to re-introduce a system of obtaining written comments. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. EVIDENCE: A copy of the NVQ level 4 for Registered Manager’s (Adult services) was on display in the entrance hall. The manager said that previously she qualified as Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 24 a mental health nurse and that when training courses or training sessions take place in the home she takes part in these. The home has a development plan. A discussion took place regarding obtaining feedback on the quality of the service provided. Although survey forms have been used in the past the manager said that this practice had stopped due to a poor response. Verbal feedback is obtained from residents on a daily basis or at review meetings or at residents’ meetings. Verbal feedback is obtained from relatives when they visit the home or if they attend review meetings. It is obtained from placing authorities when social workers visit the home or when review meetings are held. A statutory requirement was identified during the previous inspection that staff undertake food hygiene training. The member of staff on duty who was preparing the meal confirmed that she had received food hygiene training. A statutory requirement was identified during the previous inspection that information about the safe use of products kept in the COSHH cupboard is available to staff. This information was now available during the inspection. The testing/servicing of the fire precautionary equipment and systems, the Landlords Gas Safety Record, the portable electrical appliances and the electrical installation was up to date. Although the computer has been moved from the old office on the first floor the cable for connecting the computer to the telephone point is still lying in the entrance hall. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 25 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 X 2 X 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 26 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 YA9 Regulation 13.4 Requirement That recorded risk assessments are on file for using the kitchen and for taking part in annual holidays. That records of the core temperature of meat etc that is served in the home are up to date and complete. That bags of food in the freezer and the bag of rice in the cupboard are securely tied, after use. That the paper towel dispenser in the kitchen is kept stocked. That the date on which the CRB disclosure is returned is recorded, as CRB disclosures are not portable from one employer to the next. That the content and distribution of the quality assurance survey form is review and the use of the form re-introduced. Timescale for action 01/08/06 2 YA17 16.2 01/07/06 3 YA17 16.2 01/07/06 4 5 YA17 YA34 16.2 19.1 01/07/06 01/07/06 6 YA39 24.1 01/10/06 Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 27 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 2 3 4 5 6 Refer to Standard YA6 YA14 YA19 YA24 YA35 YA42 Good Practice Recommendations That minutes of review meetings include a list of persons attending. That a recorded risk assessment is kept on file for the resident that has not been provided with a television in their bedroom. That the home draws up a health action plan for the newest resident. That the Christmas cards are removed from the lounge. That the training and development plan is reviewed and updated annually. That the cable for connecting the computer (which has now been moved) to the telephone point is removed from the entrance hall. Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Matthew Residential Care Limited DS0000067553.V293573.R01.S.doc Version 5.1 Page 29 - 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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