Inspection on 23/01/07 for Nas House

This inspection was carried out on 23rd January 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nas House 07/11/05

Nas House 01/02/05

Nas House 11/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Nas House 370 Bensham Lane Thornton Heath Croydon Surrey CR7 7EQ Lead Inspector James Pitts Key Unannounced Inspection 23rd January 2007 10:30a Nas House DS0000025815.V326066.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 Nas House DS0000025815.V326066.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. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nas House Address 370 Bensham Lane Thornton Heath Croydon Surrey CR7 7EQ 020 8684 3165 F/P 020 8684 3165 asadsuad@aol.com 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) Mr Ahmed Fawzi Mungar Mr Ahmed Fawzi Mungar Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow three specified service users over the age of 65 to be accommodated. 7th November 2005 Date of last inspection Brief Description of the Service: Nas House is located centrally within the local community of Thornton Heath, close to shops, local library and good public transport - with busses just at the top of the road (a main bus interchange point a couple of stops away) and Thornton Heath Railway station is also close by. Set in an ordinary street, the home is indistinguishable as a care home and looks similar to the other houses in the area. Operating since 1985, the home provides for fourteen people with past or present mental ill health, principally in single rooms, but with six people sharing three double bedrooms. The communal spaces and large rear garden provide various pleasant and comfortable spaces for the occupants, ensuring that people don’t get ‘on top of one another’. Toilets are provided on each floor and bathrooms on the three upper storeys. A small quiet room is provided on the second floor, a TV lounge on the ground, and a large Lounge / Diner is at lower ground level leading out into the grassed and terraced rear garden. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a Tuesday morning. There were approximately half of the service users at home during the visit. The comments that were made by service users did not indicate that there were any concerns about their care. Letters of compliment that had been written by relatives were also seen and these showed a significant amount of satisfaction about how the home cares for the people who live here. What the service does well: What has improved since the last inspection? What they could do better: In two cases the home are still awaiting the minutes of service users CPA review and in one case a plan was undated. The home must chase these matters up with the placing authorities responsible. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 6 Mr Mungur used to carry out annual appraisals for staff although this has now stopped. A system for annual appraisals that then lead to an annual training and development plan must be re-established. It is also necessary for the topics discussed at supervision to be broader and noted in more detail as the notes that were seen indicate that the discussions that take place are very limited, often to only one topic. It is also necessary to carry out a more comprehensive quality assurance procedure at least once each year. This needs to include not only service user views, but also those of visiting professionals and family of each service user. It is also necessary for the policies and procedures that are in use at the home to be reviewed and updated in order to reflect changes to legislation and professional practice in recent years. It would be advisable for the home to look at refurbishing the bathrooms in the next year as these are beginning to look worn and it need of it. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Nas House DS0000025815.V326066.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 Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 2 & 3 were examined at this inspection. The service users can feel confident that the home will continue to only care for people that the staff are able to care for. EVIDENCE: Service users do not come to live at the home unless the staff get all of the proper information that helps to decide if the person can be properly cared for here. One service user left the home last year and one new service user moved in. The home received all of the relevant information in order to assess whether this person could be offered a service and a proper review of the placement has occurred It is very clear that the staff that work at the home are still able to meet the needs of all of the people who live here at the moment. Three people are over 65 years of age, however, the home is still able to meet their needs. Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 6, 7, 9 & 10 were examined at this inspection. The service users can feel confident that staff know what they need. Service users can also be assured that the staff will make sure that each person who lives at the home is allowed to live the sort of life that they choose, within acceptable risks. EVIDENCE: All of the service users continue to have a service user plan, and four of these were examined in detail. These plans are based on those that are written for people who suffer from mental health problems (Known as the Care Programme Approach). However in two cases the home is still awaiting the minutes of their CPA review and in one case a plan was undated. The home must chase these matters up with the placing authorities responsible. Each of Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 10 the service users sees their Psychiatrist regularly and many also see their CPN (Community Psychiatric Nurse). Because service users do see these people so regularly this helps to make sure that if anyone starts to become unwell then they can get the help that they need very quickly. The care plans that the home writes are updated but do not change very often as each of the service users is very settled in the way in which they choose to live their life. Some placing authorities have told the home that they do not hold a review about each person that is placed here each year. As long as the home continues to carry out their own review and then tell the placing authorities of the outcome then this should not be a significant problem. The service users all continue to get involved in things like choosing what food to and eat arranging their social and leisure activities. Most of the people who live here remain very independent and do not often need staff to help them to go out or to do the things that they want to do. The home writes a risk assessment for each of the service users. A risk assessment tells the staff how to make sure that each of the service users is kept safe from anything that might harm them. The staff were told at the previous inspection that they do need to get better at looking at the risk assessments more regularly to make sure that these are changed if they need to be. This has now happened although once again the risk assessments do not often require much change. The staff are still very good at making sure that nobody is told anything about any of the service users unless the person is allowed to know. The staff are also very good at making sure that they tell the right people about things that are happening to the people who live here. But they only tell those people that are allowed to know. The home has a confidentiality policy, as mentioned in the reports of previous inspection visits, that tells staff about how to make sure that they keep to this. Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standards 12, 13, 15, 16 & 17 were examined at this inspection. Service users can feel confident that the staff of the home will provide active support for each person to participate in the community both in terms of the activities of daily life and leisure interests. The opportunity for each service user to develop and maintain personal and family relations is also offered and is encouraged and supported by the staff team. EVIDENCE: Most of the service users go to drop in centres, and those that do not choose their own activities. Sometimes the staff do need to give a lot of support to some people who may not be very keen to go out very often. All of the service users are physically able to use buses and trains, and most do this without needing any support from the staff. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 12 The staff are very good at helping each service user to keep in contact with their families and friends. Family and Friends are made very welcome when they visit the home and some of the service users go to visit their families, often staying for weekends and even longer. There are not many rules at this home. The most important one is that no one is allowed to smoke in his or her bedroom. This is for safety reasons in case some one might fall asleep and drop their cigarette, which could start a fire. All of the people who live here are allowed to use the entire house, except other people’s bedrooms or the office. Everyone has their own front door key and a key to their own bedroom. All of the service users control their own money, with help from their family if needed. The staff at the home do not have any say in what service users spend their personal money on. The choices that service users make for what they eat at breakfast and lunch are written down on individual menu sheets. If anyone chooses to have something else, other than what is on the rotating menu, then this is written down also. Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 18, 19 & 20 were examined at this inspection. Service users can feel confident that they will get the right support to take care of their personal and healthcare needs. Anyone who needs to take medicine regularly to help them stay well will get the proper support from staff to make sure that this happens. EVIDENCE: None of the service users needs technical aids or equipment to help them to be as independent as possible. Each service user has a care plan that tells the staff in great detail the way that each service users wants to be cared for and supported, and about what each person likes or does not like. None of the service users needs help to wash, have a bath or to dress. The staff do sometimes need to encourage some people to do this, but usually this is not a problem. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 14 All of the people who live at the home usually go to see a local GP if they are not feeling well. The service users can see any local GP that they want to. The staff are write down anything that happens if anyone becomes unwell. If any of the service users have an illness or something else is wrong with them then the staff do know what this is and how to help them to get the treatment that they need. Some of the service users need to take medicine every day and the staff are very good at making sure that this happens so that they can stay well. The staff are also good at making sure that no one can get hold of any medicine that they should not have and so they keep medicines locked away. The staff also make sure that medicines are handled properly to help to keep everyone safe. All of the service users who need to take medicine have to have help from the staff to do this. The home has added to each service users medication profile the reason why they need to be supported to take their medicines, as was required at a previous inspection. The home also has an agreement, most recently updated on 10/01/07, for a local pharmacist to visit and provide advice on the safe storage and administration of medicines. Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 22 & 23 were examined at this inspection. The service users can feel confident that the staff team at the home know what to do if there are complaints or concerns about abuse. The home has clear guidance for staff about the procedures to be followed in either of these circumstances. EVIDENCE: The service users are given clear information about how to complain and what happens when they make a complaint. No complaints have been made by any of the service users or by anyone else who either visits or works at the home for around 5 years. No complaints have been made to the Commission. The staff team are good at making sure that all of the service users are protected from abuse (this means that the staff at the home do everything that they can to stop any of the service users from being hurt by someone else). The staff know what they then have to do to keep people safe. None of the service users who chatted during this visit said that they are being hurt by anyone else. There have been no serious reportable incidents at this home for at least the last five years. Nas House DS0000025815.V326066.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 24 & 30 were examined at this inspection. The service users can feel confident that they are living in a maintained and clean home. EVIDENCE: The home is comfortable and the staff do the right things to make sure that the house is a safe place for the service users to live. Mr Mungar writes in a maintenance book what decoration and replacements have taken place and when new items are purchased for the house. The house is also kept clean and is free of any unpleasant odours. It would be advisable for the home to look at refurbishing the bathrooms in the next year as these are beginning to look worn and it need of it. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards 32, 34, 35 & 36 were examined at this inspection. Service users can feel confident that there will be enough staff on duty each day to meet their needs and that these staff are safe and generally properly trained in how to support them. EVIDENCE: Four of the staff have already obtained their NVQ qualifications and one other is about to start doing this at a nearby college. The home has enough staff working each day to make sure that they can properly support the service users. There have been no new staff come to work at the home since the previous key standards inspection in August 2005. Mr Mungar has a list of in house training sessions that he conducts with staff, and these now include more externally run courses, examples of which are as follows; Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 18 Medication, Role of c/p/n (Community Psychiatric Nurse), The concept of social Psychiatry, Suicide and the suicidal resident The schizophrenia and paranoid resident First aid Medical care in schizophrenia Mr Mungur used to carry out annual appraisals for staff although this has now stopped. A system for annual appraisals that then lead to an annual training and development plan must be re-established. Staff supervision (this is a time that each member of staff spends talking about how they are getting along in their work) is done by the manager. Staff are supposed to meet with their manager at least 6 times a year by law. Mr Mungar, as the manager of the home, has continued to make sure that this happens. However, it is necessary for the topics discussed at supervision to be noted in more detail as the notes that were seen indicate that the discussions that take place are very limited, often to only one topic. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards 37, 39, 41 & 42 were examined at this inspection. The service users can feel confident that they are living in a home that is usually well managed, although establishing a proper quality assurance system and review / updating of policy and procedure would support this even further. The necessary health and safety checks are properly carried out. EVIDENCE: Mr Mungur has achieved the Certificate in Management Studies and was awarded the NVQ level 4 qualification certificate on 20/09/06. The law says that the owner the home, or their representative, must visit the home at least once a month to check on how well the service users are being Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 20 cared for and about how well the home is run. As the manager of the home is also the owner this does not need to happen at Nas House. Mr Mungar has recently issued service users with satisfaction surveys. It is also necessary to carry out a more comprehensive quality assurance procedure at least once each year. This needs to include not only service user views, but also those of visiting professionals and family of each service user. Mr Mungur has developed a business plan covering the period 2006 to 2008. The annual quality assurance audit would enhance the homes ability to make any changes to the goals of this plan. It is also now necessary for the policies and procedures that are in use at the home to be reviewed and updated in order to reflect changes to legislation and professional practice in recent years. The following health and safety checks have been carried out within the last year: Fire Alarm System: Fire Extinguishers: Gas Safety Check: 24/11/06 20/11/06 02/02/06 (this will need renewing soon) Electrical Installation: 20/02/06 Legionellosis: Portable appliances: 30/01/06 (this will need renewing soon) 17/08/06 The home is good at making sure that the people who live and work here are kept safe from fire and other hazards. Mr Mungar carries out a monthly health & safety check of the house and garden. The LFEPA (London Fire Brigade) visited the home on 4th January 2006 for a routine inspection. The report from that visit shows that there were no fire safety concerns evident at the home at that time. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 21 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 3 3 3 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 3 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X 2 3 X Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 22 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 YA6 Regulation 15 (1) ( c ) Requirement In two cases the home are still awaiting the minutes of service users CPA review and in one case a plan was undated. The home must chase these matters up with the placing authorities responsible. Timescale for action 23/04/07 2. YA35 18 (1) ( c ) (i) Mr Mungur used to carry out 23/04/07 annual appraisals for staff although this has now stopped. A system for annual appraisals that then lead to an annual training and development plan must be re-established. It is necessary for the topics discussed at supervision to be broader and noted in more detail as the notes that were seen indicate that the discussions that take place are very limited, often to only one topic. It is also necessary to carry out a more comprehensive quality assurance procedure at least once each year. This needs to include not only service user views, but also those of visiting DS0000025815.V326066.R01.S.doc 3. YA36 18 (2) 23/04/07 4. YA39 24 (1) & (3) 23/04/07 Nas House Version 5.2 Page 23 professionals and family of each service user. 5. YA41 24 (1) It is necessary for the policies 23/04/07 and procedures that are in use at the home to be reviewed and updated in order to reflect changes to legislation and professional practice in recent years. 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 YA24 Good Practice Recommendations It would be advisable for the home to look at refurbishing the bathrooms in the next year as these are beginning to look worn and it need of it. Nas House DS0000025815.V326066.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nas House DS0000025815.V326066.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. 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