Inspection on 07/11/05 for Nas House

This inspection was carried out on 7th November 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nas House 23/01/07

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 Unannounced Inspection 7th November 2005 12:05 Nas House DS0000025815.V262865.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 Nas House DS0000025815.V262865.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. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Nas House Address 370 Bensham Lane Thornton Heath Croydon Surrey CR7 7EQ 020 8684 3165 020 8684 3165 famungar@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.V262865.R01.S.doc Version 5.0 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. 8th August 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.V262865.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Most of the people who live at Nas House have done so for a long time, and know each other very well indeed. Most of the staff have also worked at the home for quite some time too so everyone knows each other. This inspection took place during the daytime and there were six service users at home, three of whom wished to chat to say what they think about living here. The comments that were made were positive and none of these people said that they had any concerns about how they are cared for. Mr Mungar, the owner and manager was also present during this visit. This is the home’s second unannounced inspection visit this year as the Commission is focusing more on unannounced rather than announced inspections. Most of the core standards were examined at the previous visit that took place in August. This visit focused on looking at the progress that has been made with the small number of requirements that were made previously and the small number of key standards that still needed to be looked at. What the service does well: What has improved since the last inspection? What they could do better: The staff must, however, still add to each of the service user’s medication profiles the reason why they need to be supported to take their medicine. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 6 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. Nas House DS0000025815.V262865.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 Nas House DS0000025815.V262865.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): 2&3 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: New 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. There have been no new service user move into the home since before the inspection that took place in 2004. 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, although these people are still being properly cared for. Nas House DS0000025815.V262865.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, 7, 9 & 10 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. EVIDENCE: All of the service users continue to have a service user plan. These plans are based on those that are written for people who suffer from mental health problems (Known as the Care Programme Approach). Each of the service users see’s 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. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 10 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 one service user’s risk assessment could not be found and Mr Mungar said that he would let the Commission know when it is located. 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 pre3vious inspection visits, that tells staff about how to make sure that they keep to this. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The service users can feel confident that they do have the opportunity to choose what to eat and also when to eat. EVIDENCE: 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 too. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 20 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: 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 staff must, however, still add to each of the service user’s medication profiles the reason why they need to be supported to take their medicine. It is, however, noted that since the previous inspection Mr Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 13 Mungar now writes on the bottom of each service users monthly medication chart that they need to be supervised by staff when taking their medicine. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The 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. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 15 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 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. An example of this is the new bedroom curtains that were delivered on the day of this visit for 5 of the bedrooms, each chosen by the service users who were having their curtains replaced. The house is also kept clean and is free of any unpleasant odours. Nas House DS0000025815.V262865.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): 32, 33, 35 & 36 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: Three of the staff have already obtained their NVQ qualifications and two others are currently doing this at a nearby college. Mr Mungar has agreed to write to the Commission to outline the current situation with regard to NVQ qualifications for the staff team. 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 last year. Mr Mungar has a list of in house training sessions that he conducts with staff; however, it would also be advisable for the staff team to be offered the opportunity to attend externally run training courses. 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 Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 17 Mungar, as the manager of the home, has continued to get better at making sure that this happens and this requirement has now been met. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The service users can feel confident that they are living in a home that is well managed. The necessary health and safety checks are properly carried out. EVIDENCE: The manager said at the last inspection that he had completed the Certificate in Management Studies and that a copy of the certificate would be sent to the Commission. This has now happened. 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 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 would be advisable for Mr Mungar, when renewing the annual development plan which will need to be done in early 2006 to ensure that any matters that are highlighted in these surveys are included in future developments for the home. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 19 The following health and safety checks have been carried out within the last year: Fire Alarm System: 01/12/04 Fire Extinguishers: 15/02/05 Gas Safety Check: 31/01/05 Electrical Installation: 17/02/04 Legionellosis: 31/01/05 Portable appliances: 12/08/05 (a copy of a certificate confirming this check was sent to the Commission as required at the previous inspection visit) The home is good at making sure that the people who live and work here are kept safe from fire and other hazards. The only problem that had existed at the time of the previous inspection was that health and safety risk assessment had not been updated since 10th June 2003. This now happens regularly as Mr Mungar has introduced a monthly check of the house and garden. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X x 3 LIFESTYLES Standard No Score 11 x 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score x 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Nas House Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 X X 3 X DS0000025815.V262865.R01.S.doc Version 5.0 Page 21 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 YA20 Regulation 13 Timescale for action The staff must add to each of the 07/11/05 service user’s medication profiles the reason why they need to be supported to take their medicine (this is an oustanding requirement from the previous inspection). Requirement 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 Refer to Standard YA9 YA35 YA39 Good Practice Recommendations The home should inform the Commission once the missing service user risk assessment is located. It would also be advisable for the staff team to be offered the opportunity to attend externally run training courses. It would be advisable for Mr Mungar, when renewing the annual development plan which will need to be done in early 2006 to ensure that any matters that are highlighted in the service user surveys are included in future developments for the home. Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Nas House DS0000025815.V262865.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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