Inspection on 24/04/07 for Onkar Care Home

This inspection was carried out on 24th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Onkar Care Home 03/12/08

Onkar Care Home 08/10/08

Onkar Care Home 02/10/08

Onkar Care Home 27/04/06

Onkar Care Home 14/11/05

Onkar Care Home 28/04/05

Onkar Care Home 10/12/04

Onkar Care Home 17/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Onkar Care Home 15 Portman Street Leicester Leicestershire LE4 6NZ Lead Inspector Martin Hefferman Key Unannounced Inspection 24th April 2007 09:30 Onkar Care Home DS0000046349.V335221.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 Onkar Care Home DS0000046349.V335221.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. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Onkar Care Home Address 15 Portman Street Leicester Leicestershire LE4 6NZ 0116 2516443 0116 2246952 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 Harjap Singh Riyat Mr Jaspal Singh Riyat Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10), of places Physical disability (3) Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service user numbers: No one falling within category LD may be admitted into Onkar Care Home where there are 10 persons of category LD already accommodated within this home. Service user numbers: No one falling within category PD may be admitted into Onkar Care Home where there are 3 persons of category PD already accommodated within this home. Service user category: No person falling within category PD may be admitted to Onkar care home unless that person also falls within category LD - ie dual disability. To specify suitable facilities: The service users admitted to Onkar Care Home who fall within category PD may only be accommodated on the ground floor. Service user numbers: No one falling within category MD may be admitted into Onkar Care Home where there are 10 persons of category MD already accommodated within this home. Service user category: No person falling within category MD may be admitted to Onkar care home unless that person also falls within category LD - ie dual disability. No person to be admitted to Onkar Care Home in categories LD, PD or MD when 10 persons in total of these categories/combined categories are already accommodated in this home. 27th April 2006 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Onkar Care Home is registered to provide care for 10 adults with learning disabilities, all of whom may have additional mental health problems and three of whom may have a physical disability. The home is located in a residential area with easy access to public transport and the city of Leicester. The property consists of two floors and has ten single bedrooms all with en-suite facilities. There are a variety of aids and adaptations throughout the home based on residents assessed care needs. At the time of the inspection, fees ranged from approximately £329 to £751 per week. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A visit to Onkar Care Home took place on 24th April 2007, lasting approximately three and three quarter hours. The main method of inspection used on that day was ‘case tracking’ which involved selecting three people who live at the home and tracking the care they receive through review of their records, discussion with them & staff and observation of care practices. The inspection also took account of all information received since the date of the last visit. A pre-inspection questionnaire and comment cards had not been received at the time of writing this report. What the service does well: What has improved since the last inspection? What they could do better: A record must be kept of the food provided for the people who live at the home in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. People who live in the home must have access to appropriately maintained grounds. Two written references must be obtained before employing staff to work in the home to ensure that the people living there are fully protected. The findings from stakeholder surveys should be published. Daily records should be reviewed to ensure they detail the activities that have taken place. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 6 The advice of the Fire Authority should be sought to ensure that fire tests are completed at the proper frequency. 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. Onkar Care Home DS0000046349.V335221.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 Onkar Care Home DS0000046349.V335221.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment practices are effective, ensuring that individual needs are identified and can be met. EVIDENCE: Information about Onkar Care Home was available at the time of the visit. A senior member of care staff stated that an up-to-date copy of the guide had been completed to reflect recent changes to the home. She agreed to forward a copy to the Commission. Each of the files that were inspected contained a community care assessment completed by a social worker. The home had also completed its own assessments / care plans. The individual needs of the people who were chosen for the purposes of case tracking had been clearly identified during the assessment process. Onkar Care Home DS0000046349.V335221.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members have the information they require to meet the needs of people living in the home. EVIDENCE: Individual plans were available for the people who were chosen for the purposes of case tracking. The plans that were inspected appeared to be clear and comprehensive. Risk assessments have been completed detailing the measures to be taken to minimise any risks that have been identified. A senior member of care staff agreed to ensure that a record is kept whenever individual plans & risk assessments are reviewed. Staff members were observed offering choice to one of the people who were chosen for the purposes of case tracking using her preferred method of communication. It was noted that all of the residents who were present at the time of the visit were encouraged to make decisions about their own lives with staff providing assistance when required. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements relating to the various aspects of residents’ lifestyles are generally well managed ensuring that their needs are met. EVIDENCE: One of the people who were chosen for the purposes of case tracking attends day services four days a week. A second – who had recently moved to Onkar Care Home for a short-stay – stated that she attends a social group and a local college. A senior member of care staff reported that arrangements were being made for the third person to attend a day centre. Daily records indicate that people who live at the home are encouraged to use community facilities such as local shops & parks. One resident had attended the recent Vaisakhi celebrations. It was noted that some of the entries in people’s daily records were brief and did not detail the daily activities that had taken place (see ‘Conduct & Management of the Home’). Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 11 People who live at the home are encouraged to maintain contact with their families & friends. One of the people who were chosen for the purposes of case tracking visits her mother at a nearby care home for older people. A second resident was in the process of arranging to stay with her family at the time of the inspection. Residents appeared to enjoy the meals that were provided on the day of the inspection. Individual plans contain information about residents’ dietary requirements including those associated with their faith. Relevant requirements were being met at the time of the visit. A senior member of care staff stated that a record had not been kept of the meals provided to people living in the home. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal support & healthcare needs are met. EVIDENCE: People who live at the home stated that they are happy with the support they receive. Individual plans detail any personal care required by each resident and any preferences that have been identified. They also set out details of any healthcare needs and of any action felt necessary as a result. Records indicate that contact is made with healthcare professionals when necessary. None of the people who were chosen for the purposes of case tracking manage their medication. Records of the medicines administered to two of them met relevant requirements. A senior member of care staff stated that the pharmacist would produce an administration record later that day for a resident who had moved in on an emergency basis the day before. Staff members have received medication training. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. 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. People who live at the home are protected by its arrangements for handing complaints and responding to allegations of abuse. EVIDENCE: The complaints procedure is set out in the information that has been produced about the home. A senior member of care staff stated that no complaints had been received since the date of the last inspection. The home has policies and procedures on the protection of vulnerable adults and whistle blowing. The senior indicated that she was aware of the action to be taken in the event of an allegation or suspicion of abuse. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely environment. They did not however have access to suitable grounds at the time of the visit. EVIDENCE: The areas of the home that were inspected were decorated and furnished to a satisfactory standard. They appeared to be clean and tidy. People who live in the home have been encouraged to personalise their rooms. One of the rooms that were inspected contained items associated with the resident’s faith. All of the bedrooms have ensuite toilets. Facilities downstairs are adapted to meet the needs of people with a physical disability. It was noted that the grounds of the home were not in a suitable state for people who live there to use. A senior member of care staff stated that the owner planned to pave an area to the rear of the home so that it could be used for barbeques and that in the interim residents were able to use nearby parks. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 15 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, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by trained staff. They are not however fully protected by the home’s recruitment practices. EVIDENCE: Records indicate that one written reference had been received for two members of staff, both of whom had been employed over a year prior to this inspection. A senior member of care staff stated that a second verbal reference had been obtained for both of them. Criminal Records Bureau disclosures were available for inspection. The senior agreed to check staff records to ensure that they contain all of the documents required under Schedule 2 of the Regulations, including proof of identity. Staff members have completed an induction programme based on the Learning Disability Award Framework. A senior member of care staff has obtained National Vocational Qualification level 2. Two members of staff are due to start the award later in the year. At the same time, the senior will start NVQ level 3. Records indicate that staff members have received training on issues relevant to their work. The senior stated that a staff member identified at the time of Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 16 the inspection would renew her food hygiene qualification - which had recently expired – at the earliest opportunity. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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 a generally well run home. EVIDENCE: The registered manager has completed National Vocational Qualification level 4 and the Registered Managers’ Award. A senior member of care staff stated that the home completes a survey of the views of relevant stakeholders twice a year. She reported that any issues that were identified had been addressed but that the home had not published the findings. Whilst the requirements of standard 41 (record keeping) were not inspected on this occasion, it was noted that some of the entries in people’s daily records did not detail the daily activities that had taken place. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 18 Staff members have received training on issues such as first aid, food hygiene & manual handling. Records indicate that fire tests take place monthly. A senior member of care staff was reminded that fire doors must not be wedged open. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA17 Regulation 17(2) Requirement A record must be kept of the food provided for the people who live at the home in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory. People who live at the home must have access to appropriately maintained grounds. People who live at the home must be protected by thorough recruitment practices - two written references must be obtained before employing staff to work in the home. Timescale for action 31/05/07 2 YA24 23 30/06/07 3 YA34 19 31/05/07 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 YA39 Good Practice Recommendations The findings from stakeholder surveys should be published. DS0000046349.V335221.R01.S.doc Version 5.2 Page 21 Onkar Care Home 2 3 YA41 YA42 Daily records should be reviewed to ensure they detail the activities that have taken place. The advice of the Fire Authority should be sought to ensure that fire tests are completed at the proper frequency. Onkar Care Home DS0000046349.V335221.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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