Inspection on 20/08/07 for Natal Road (36)

This inspection was carried out on 20th August 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Natal Road (36) 13/10/06

Natal Road (36) 02/02/06

Natal Road (36) 12/07/05

Natal Road (36) 02/03/05

Natal Road (36) 28/06/04

Natal Road (36) 02/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Natal Road (36) 36 Natal Road Ilford Essex IG1 2HA Lead Inspector Harbinder Ghir Unannounced Inspection 20 and 21st August 2007 10:00 th DS0000025911.V348305.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 DS0000025911.V348305.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. DS0000025911.V348305.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Natal Road (36) Address 36 Natal Road Ilford Essex IG1 2HA 020 8514 8689 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) Mrs Sumiran Sharma Mrs Veena Mehta Mrs Veena Mehta Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000025911.V348305.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate level of disability. Date of last inspection 13th October 2006 Brief Description of the Service: 36 Natal Rd is a residential home registered to care for three younger adults with learning disabilities. The service currently has one vacancy. The home is a terraced house in a residential area close to Ilford town centre, with good public transport links, and other community facilities. The house is an ordinary domestic property, which is adequately maintained and appropriately furnished. All the service users occupy single bedrooms. Shared facilities include a lounge/dining room. A small garden is also available for the service users enjoyment. One bedroom is located on the ground floor as well as a toilet/ shower. There are two bedrooms upstairs plus a staff sleeping in room and a bathroom/toilet shared between the service users upstairs. The manager and staff ensure that the service users enjoy an active social life via membership of various groups and organisations. Fees in the home, which have been taken from the services latest version of the Statement of Purpose currently, range from £820 to £865 per week, dependent on individual staff support levels. DS0000025911.V348305.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by Regulation Inspector Harbinder Ghir. The inspection took place on the 20th August 2007 between 10.00am and 2.30pm and on the 21st August 2007 between 10.30am and 11.30am. During the inspection the inspector was able to talk to residents residing at the home and members of staff. The community learning disabilities nurse was also spoken to. The London Borough of Redbridge who is the host authority for the service was contacted, inviting their comments on the service they are commissioning, which have been included in the report. As part of the inspection the inspector toured the home, read records of people who use the service and examined documents in relation to the management of the home. At the end of the inspection the inspector was able to provide feedback to the manager. The inspector would like to thank everyone involved in the inspection process. What the service does well: The service completes comprehensive pre-admission assessments, to ensure service user’s individual aspirations and needs are assessed. The right for residents to exercise choice and control is promoted by the service and they are actively consulted on, and participate in, all aspects of life in the home. Residents receive personal care and support in the way they prefer. All staff have received up to date training in Adult Protection, which ensures the protection of residents. The décor of the home is of a good standard and provides a homely and pleasant living environment enhancing residents’ comfort. Recruitment practices are robust and ensure residents are in safe hands at all times. Adequate staff training is provided to all care staff, to ensure they are equipped with the skills and are competent to do their jobs. Residents can be confident that the staff team who care for them benefit from regular supervision. DS0000025911.V348305.R01.S.doc Version 5.2 Page 6 Service users’ financial interests are safeguarded. The welfare of staff and residents is promoted by the home’s policies and procedures. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can DS0000025911.V348305.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. DS0000025911.V348305.R01.S.doc Version 5.2 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 DS0000025911.V348305.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service completes comprehensive pre-admission assessments, to ensure service user’s individual aspirations and needs are assessed. All service users do not have an individual written contract to ensure they are in agreement with the statement of terms and conditions of the home. EVIDENCE: The service currently has one vacancy and the care plan files for the two service users residing at the home were closely examined. Both service users have resided at the home since 1997/1998. The service had obtained care management assessments from placing authorities at the time of their admissions. For new prospective residents, the service has a comprehensive pre-admission policy and procedure in place. On viewing service user files, one service user had a contract of residency, but was not signed by the resident or the manager of the home; the other resident did not have a contract. All service users must be issued with an individual written contract, which they or their representatives and the manager of the DS0000025911.V348305.R01.S.doc Version 5.2 Page 10 service must sign to ensure, they have agreed to terms and conditions of the service. This will be stated as Requirement 1. New prospective residents are able to visit the home as many times as they like and have an opportunity to stay overnight. Relatives and family are also invited to visit the home. On speaking to residents residing at the home, they both commented that they “like living at the home.” One resident stated, “I like the carers, and I do what I like”. It was evident from observing staff, daily case recording sheets, residents’ care plans that staff working at the home were able to meet the needs of residents. DS0000025911.V348305.R01.S.doc Version 5.2 Page 11 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): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive, but are not always updated to reflect the changing needs of people who use the service. The right for residents to exercise choice and control is promoted by the service and they are actively consulted on, and participate in, all aspects of life in the home. Risk assessments are undertaken routinely, to ensure residents are supported to take risks as part of an independent lifestyle, but these are not always updated according to residents’ changing needs. EVIDENCE: Care plan files were closely examined and care plans were comprehensive and covered all aspects of physical, mental and communication needs of residents. DS0000025911.V348305.R01.S.doc Version 5.2 Page 12 Areas covered also included the likes and dislikes of residents, their dietary needs, personal care and hygiene, mobility, communication needs, maintaining a safe environment, mental health needs, personal finances, community participation, interests and hobbies and relationships. However, care plans did not always reflect the changing needs of residents and were not updated accordingly. For one resident in regards to identifying their spiritual and religious needs, their care plan after being reviewed in March 2007 stated “X continues to attend church on a Sunday morning. Staff must continue to encourage her to address her spiritual and religious needs.” However, on speaking to a member of staff and examining daily case recording sheets there was no indication that the resident attended church. The staff member also stated “X stopped going to church last year and doesn’t want to go anymore.” For another resident they informed the inspector that they can self medicate and this was also confirmed with the member of staff on duty. However, on viewing the resident’s care plan, it informed that the resident could not self medicate and the resident had signed a consent form to give staff permission to administer his medication. The resident informed the inspector that they also did not attend church. On viewing the care plan, it again contained incorrect information and stated that the resident attended church every Sunday. From this information it is evident that care plans are not reviewed with residents, resulting in inaccurate information being recorded on care plans which does not reflect their changing needs and preferences of people who use the service. A requirement in relation to the above findings will be stated as Requirement 2. Risk assessments were completed for residents and identified risk areas in care plans included moving and handling, epilepsy, seizures, out in the community and self-harm. Risk assessments included clear guidelines for staff in how to manage risks posed to people who use the service. Risk assessments were reviewed regularly but were not always amended, according to the changing needs of residents. In regards to the above information, the risk assessment for a resident who was self-medicating had not been completed according to his changing needs. For another resident who had recently suffered a serious fall at the home and whose mobility had become unsteady, the risk assessment had not been updated. Although a risk assessment in relation to mobility was in place, the assessment did not include information in relation the resident being at risk of falling following their fall. A requirement in relation to the findings will be stated as Requirement 3. Residents were involved in the daily running of the home as far as their abilities allowed. One resident was observed to lay the table, to clear up after finishing their meal and asking staff if they wanted any help. Residents were also encouraged to express their views in resident meetings on the running of the home and changes they would like made, which were held every two months. DS0000025911.V348305.R01.S.doc Version 5.2 Page 13 DS0000025911.V348305.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with support to maintain their independence and in areas of personal development according to their needs and wishes. Residents are engaged in community life, promoting their opportunities to be part of the local community. Daily routines respect the rights of residents ensuring their needs are met the way they prefer. Residents are offered meals that promote their choices and respect their individual preferences. Residents are supported to maintain family links and relationships inside and outside the home. EVIDENCE: DS0000025911.V348305.R01.S.doc Version 5.2 Page 15 Each resident has an individual activity programme, which is devised according to his or her preferences. Due to the dependency level of residents, finding jobs is not an appropriate option for them. Residents are encouraged to be part of the local community. They participate in leisure activities in the community including shopping, going to the library, going out to eat and going to the cinema. Residents are given the choice to attend a place of worship of their choice, which at the moment both residents have declined. Residents are going for their annual holiday to Clacton on sea this year, choosing the destination themselves. One resident attends a day centre four days a week, and whilst there is able to participate in outings, aromatherapy sessions and develop daily living skills. Another resident has now retired from attending an Open College Network and was able to take part in educational courses. The London Borough of Redbridge Commissioning Unit was contacted as part of the inspection and as a result of their random visit to the service, which took place last year they have found that “There is a reasonable amount of activities and a good amount of community involvement for residents at the home.” Staff support residents to maintain family links and friendships inside and outside the home. One resident stated, “I have a girlfriend, who I see at the day centre.” Residents’ families can visit anytime and residents can meet family and friends in private or in their bedrooms. The home provides meals, which are varied and nutritious which meet the dietary needs of residents. There is a four weekly menu, which offers a choice of two hot meals at the evening meal and a variety of snacks and drinks throughout the day. Residents could choose to eat out if they preferred or request something different to the menu option. On the day of the inspection, residents by refusing the option on the menu and requested fish and chips, which they had at lunchtime and stated that they had “enjoyed.” The daily nutritional intake for each resident is recorded, to ensure his or her nutritional intake was monitored. Daily routines promoted the rights and choices of residents. Care plans further reflected this, as daily case recording sheets identified residents going to bed at their preferred time and getting up when they liked. One resident spoken to stated “I go to bed anytime”. DS0000025911.V348305.R01.S.doc Version 5.2 Page 16 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): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ receive personal support and care in the way they prefer and require. Medication practices do not always ensure the safety of people who use the service. The ageing, illness and death of service user are handled with respect and as the individual would wish. EVIDENCE: All residents have a detailed plan of their daily routine including the type of support needed in relation to personal hygiene, according to their level of care needs. All residents have a designated key worker to promote their privacy and dignity, and all personal care is provided in private. Attention is paid to personal preferences in relation to the provision of personal care, for example whether one prefers a shower or a bath. Personal support takes account of DS0000025911.V348305.R01.S.doc Version 5.2 Page 17 individual preferences and residents’ choice of dress and appearance is respected. A resident’s care plan identified that she liked to wear dresses, which the staff ensured by supporting her to choose her dresses from catalogues as she did not like going out. Residents are supported by staff to attend appointments with healthcare professionals and their health is closely monitored and prompt referrals are made. There was evidence of staff taking female residents to well women checks and the involvement of multli-disciplinary healthcare professionals where required were made to dentists, chiropodists, GP’s and community psychiatric nurses. Professionals spoken to, spoke positively of the staff team, in regards to meeting the needs of residents. The Community Learning Disabilities Nurse visiting at the time of the inspection was spoken to. She stated, “The resident I see seems to be happy and is happy with the care provided. The deputy manager has always turned up with the resident to her outpatient appointments and seems very able. We have had some communication difficulties with some members of staff in the past, but these were addressed by the manager and now its fine.” There are policies and procedures for the handling and recording of medicines. Each resident has a medication care plan file, including information on the residents’ current medication. A list of all staff signatures trained to administer medication was kept on the medication file. An audit was undertaken of the management of medicine within the home and a random sample of Medication Administration Records (MAR) charts were examined. The following issues were identified; Medication was stored in a locked cabinet, but the cabinet was not fixed to the wall. Medication Administration Records were not recorded in full, as staff had not signed for some entries. A written policy is required that includes the procedure to be followed and the precautions to be taken, including a witness to the transfer when medication is secondary dispensed into dosette boxes by staff for residents when leaving the home. The home has an appropriate medication policy and procedure in place, which is to protect all residents and ensures the safety of those who can self-medicate but has not utilised these by completing risk assessments for one resident who is self medicating. Medication, which was for a member of staff, was found in an unlocked kitchen draw. - - It is Requirement 4 that medication practices are reviewed to ensure the DS0000025911.V348305.R01.S.doc Version 5.2 Page 18 safety of residents. Steps have been taken to find out the wishes of residents in the event of their death, including contacting relatives or representatives where the resident is unable to express their views. However, this was only done for one resident. It is Requirement 5 the wishes of all residents where possible in the event of their death are established and recorded in their care plan. DS0000025911.V348305.R01.S.doc Version 5.2 Page 19 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): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be assured their views are listened to and acted on. However, the service needs to broaden its way of recording complaints to include concerns to ensure any dissatisfaction is recorded regardless of source. All staff have received up to date training in Adult Protection, which ensures the protection of residents. EVIDENCE: The service has a complaints procedure that is clearly written and easy to understand. It is available in picture formats, large print and is also in the process of being provided in audio format. The complaints procedure was displayed in picture format around the home and in residents’ bedrooms. The complaints logbook was seen, which had no recorded complaints. The inspector was informed that staff quickly resolves any issues before they result into complaints. The complaints form adequately recorded actions taken and the outcomes achieved. However, the registered manager needs to ensure all concerns or dissatisfactions however minor are recorded and demonstrate how these have been resolved, to ensure people who use the service are assured their views are listened to and acted upon. A resident spoken to stated “I am unhappy with one carer who serves my lunch late, I have told the staff that I want it on time”. On speaking to the deputy manager she informed that she is aware of the concerns the resident has highlighted and informed DS0000025911.V348305.R01.S.doc Version 5.2 Page 20 the inspector how they have dealt with the concern. But there was no record of the concern recorded or the actions the service took to resolve the concern. A requirement in relation the findings will be stated as Requirement 6. The policies and procedures for adult protection are available and give clear specific guidance to those using them. On speaking to staff working at the service, they demonstrated their knowledge on when incidents needed external input and who to refer the incident to. Training of staff in the area of protection is regularly arranged by the home. All staff have attended up to date training in adult protection. DS0000025911.V348305.R01.S.doc Version 5.2 Page 21 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): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable environment, but further environmental safety checks would minimise risks presented to residents. Décor is of a good standard and provides a homely and pleasant living environment enhancing residents’ comfort. EVIDENCE: The premises were comfortable, bright, airy, clean and free from offensive odours. Furnishings and fittings in communal areas were of good quality, domestic and unobtrusive. The home provides a main lounge, kitchen and a dining room. One bedroom is situated on the ground floor and a further three bedrooms are situated on the first floor, one of which is used as the office and a sleep in room for night staff. Residents’ rooms were seen during the inspection. The rooms were comfortable with adequate furnishings and were DS0000025911.V348305.R01.S.doc Version 5.2 Page 22 also personalised by the residents. One resident had personalised their room with football memorabilia. All rooms were lockable and can be overridden by staff in an emergency. Residents were given the choice of holding a key to their room, which one resident had decided to do. Specialist equipment for residents was provided where required. During a tour of the home, household hazardous products were found in an unlocked cupboard under the kitchen sink, a mop and bucket was stored into the downstairs shower room, and painting equipment and tools were stored in the upstairs bathroom. A further tour of the rear garden area identified that the area was generally unkempt with a variety of household waste was stored at the back of the garden. A log of fridge, freezer and food temperatures was seen. Staff did not consistently complete and no recordings were found for some days for fridge and freezer temperatures. All parts of the home to which residents have access to must be so far reasonably practicable made free from hazards to their safety and unnecessary risks to residents are identified and so far as possible eliminated, this will be stated as Requirement 7. DS0000025911.V348305.R01.S.doc Version 5.2 Page 23 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): 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment practices are robust and ensure residents are in safe hands at all times. Adequate staff training is provided to all care staff, to ensure they are equipped with the skills and are competent to do their jobs. Residents can be confident that the staff team who care for them benefit from regular supervision. Staffing levels were satisfactory, but records did not accurately reflect the persons on duty, which might impact adversely on residents, for example in relation to investigation of a complaint. EVIDENCE: Three staff files were closely examined, which were all in good order. References and Criminals Records Bureau checks had been obtained for all members of staff. Staff had been on induction programmes and all received ongoing training. Training received this year included training in the protection DS0000025911.V348305.R01.S.doc Version 5.2 Page 24 of vulnerable adults, moving and handling, basic hygiene and health and safety, first aid, risk assessments and infection control and fire safety. The service has a permanent staff team and does not use agency staff, which ensures a consistent service being provided to residents. Staff qualifications evidenced that the service has a ratio above 50 of NVQ qualified staff. On viewing the staff rota it did not include the full names of staff on duty. The staff rota was examined in line with the staff signing in book, where members of staff recorded the time of starting and finishing time of their shift. The rota was not an accurate reflection of staff who had actually signed in for their duties for some days. The registered manager and the deputy manager who were on the staff rota did not sign the staff signing in book. The rota was also not amended where staff had swapped shifts. It is Recommendation 1 that the staff rota is an accurate reflection of the members of staff on duty to ensure the protection of residents. Staff supervision records evidenced that staff were supervised at least six times a year, ensuring staff are provided with the skills, training and knowledge to perform the tasks required by their employment role. Members of staff spoken also commented that they were supervised regularly. All members of staff were also apprised annually to review performances against job descriptions and agree career development plans. DS0000025911.V348305.R01.S.doc Version 5.2 Page 25 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): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from an experienced manager who recognises their needs and adequately manages the home. Systems for service user consultation have been implemented, to ensure residents’ views underpin all self-monitoring, reviews and developments by the home. Service users’ financial interests are safeguarded. The welfare of staff and residents is promoted by the home’s policies and procedures. EVIDENCE: DS0000025911.V348305.R01.S.doc Version 5.2 Page 26 The registered manager of the home has completed her NVQ level 4. She has extensive experience of working with individuals with learning disabilities. The registered manager communicates a clear sense of direction, leadership and openness. Staff said they felt well supported and the manager was approachable. A member of staff stated “The manager listens to any concerns we raise and always acts upon these.” Another member of staff spoken to stated, “The manager takes my concerns seriously, if we have any complaints they deal with it”. Quality assurance surveys have been implemented by the service and evidence was seen of surveys being sent out to relatives and stakeholders in the community. Evidence of quality assurance questionnaires are also completed with residents as part of their residents’ meetings, which take place every two months and their views on running of the home are actively sought on an ongoing basis. Services users’ records of finances were viewed. All amounts were accounted correctly and were in order. Health and Safety records were inspected. All documentation was in order and appropriately completed. Evidence was seen of water temperatures checks completed at all outlets throughout the home on a monthly basis. The London Borough of Redbridge Commissioning Unit was contacted as part of the inspection. A contracts monitoring officer was spoken to who stated, “We have no concerns about the service, everything seems to be fine.” DS0000025911.V348305.R01.S.doc Version 5.2 Page 27 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 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 X 3 X X 3 x DS0000025911.V348305.R01.S.doc Version 5.2 Page 28 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 YA5 Regulation 17 Requirement The registered person must ensure that all residents are issued with an individual written contract, which they or their representatives and the manager of the service must sign to ensure, they have agreed to terms and conditions of the service. The registered persons must ensure that care plans are reviewed with residents and are amended accordingly to their changing needs and notify the resident of any such revision. The registered persons must ensure that risk assessments are updated according to the resident’s changing needs, to prevent them being placed at risk of harm or abuse. The registered persons must ensure that medication practices are reviewed to ensure the safety of residents. The registered persons must ensure that the wishes of all residents where possible in the event of their death are established and recorded in their DS0000025911.V348305.R01.S.doc Timescale for action 30/11/07 2 YA6 15 (1) (2) (a) (b) (c) (d) 30/11/07 3 YA9 13 (6) 30/11/07 4 YA20 13 (2) 30/11/07 5 YA21 12 13 30/11/07 Version 5.2 Page 29 care plan. 6 YA22 22 The registered persons must ensure that any complaint made under the complaints procedure, regardless of source is fully investigated, to ensure the views of people who use the service are listened to and acted on. The registered persons must ensure that all parts of the home to which residents have access to must be so far reasonably practicable made free from hazards to their safety and unnecessary risks to residents are identified and so far as possible eliminated. 30/11/07 7 YA26 13 (4) (a) 30/11/07 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 YA33 Good Practice Recommendations It is recommended that the staff rota is an accurate reflection of the members of staff on duty to ensure the protection of residents. DS0000025911.V348305.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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 DS0000025911.V348305.R01.S.doc Version 5.2 Page 31 - 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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