Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 12/02/09 for Percy Road, 97

Also see our care home review for Percy Road, 97 for more information

This inspection was carried out on 12th February 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

We looked at the Person Centred Plans of two residents, the PCP plans were very informative and up to date. The PCP plans were different with photographs and information about the individual. We also looked at a recent PCP on the computer that a resident and key worker were still working on. We looked at the health care records of two residents that showed that all medical appointments and health checks had been completed.

What has improved since the last inspection?

We discussed the safeguarding procedure with the registered manager and was told that all but one member of staff have done the training. The member of staff has been booked on the next training day in February 2009. The decoration of the home that was required in 2008 was completed in 2008, there are issues regarding the kitchen and a residents bedroom from this inspection. We discussed fire risk assessments and looked at the relevant records with the registered manager. The home has an evacuation plan that has been agreed with the LFEPA, all residents have an up to date risk assessment in place for their evacuation in case of a fire.

What the care home could do better:

We looked at the risk assessment records for two resident`s, one individuals risk assessments were up to date and had been reviewed in May 2008. The other residents risk assessment had not been reviewed in over a year. we were told by the registered manager that there was no change to the assessment records and that she would make sure a review takes place imminently. We looked at the MAR sheet records of all four residents. One of the residents does not take their medication at the correct times or can refuse. The information should be written on the reverse of the MAR sheet record to inform of any changes in the prescribed routine. We were told by the registered manager that the GP and other professionals were aware of the issues and we looked at records to show what actions had been taken. We had a full tour of the home looking at the decoration and fixtures and fittings. We were shown by two residents their kitchen, the units are in a bad state of repair and do need replacing with a new kitchen. The residents told us that they want a new kitchen as it was not good. We went into one of the residents bedrooms and were shown cracks in the plaster that requires filling and also that the bedroom needs to be painted. We looked at the training records of all staff working at Percy Road. One member of staff has not completed all mandatory refresher training, we were told by the registered manager that the member of staff will not be a lone worker until the training has been completed.We requested the training information on four regular bank staff sent to Percy Road. None of the staff had completed or were up to date with mandatory training, one individual had not completed the in house induction programme. The organisation must make sure that all staff sent to Percy Road have the relevant skills and are competent to do their job. We looked at the water temperatures for the home that were set at the correct temperature. The registered manager must also include the four residents hot water outlets in their bedrooms as part of the checks to make sure they are set at a safe temperature.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Percy Road, 97 Percy Road 97 Percy Road Shepherds Bush London W12 9QH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jackie Derbyshire     Date: 1 2 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: Percy Road, 97 97 Percy Road Percy Road Shepherds Bush London W12 9QH 02087430044 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : info@yarrowhousing.org.uk Yarrow Housing care home 4 Number of places (if applicable): Under 65 Over 65 0 learning disability Additional conditions: 4 The maximum number of service users who can be accommodated is: 4 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: earning disability Code LD Date of last inspection Brief description of the care home 97 Percy Road is a registered care home that provides accommodation and personal care for people with a learning disability. There are four people living at Percy Road, 2 men and 2 women. Threshold Tennant Trust Housing Association owns the property. Yarrow Housing, a voluntary organisation, provides the care. The home is located in a residential area of Shepherd?s Bush, close to shops and public transport. There is a lounge, kitchen/dining room, four single bedrooms, bathroom / WC and shower room / WC, and a small garden at the back of the house. Care Homes for Adults (18-65 years) Page 4 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: Throughout this report the word we will be used as meaning the CSCI. This unannounced inspection took place on Thursday 12th February 2009. We spent 4 hours visiting the home. We spent time talking to the registered manager, staff and people living at the home. We looked at the care records of two residents, the medication and finance records of all four residents. We had a tour of the home and three residents bedrooms were looked at as well as all communal areas. The home was clean and tidy on the day of this inspection. We received three residents surveys, comments will be included throughout this report. The four requirements set in 2008 have been met and 7 new requirements were set from this inspection. We received the AQAA document information from that will also be included throughout this report. The weekly fee for Percy Road is 1172. Care Homes for Adults (18-65 years) Page 5 of 31 Care Homes for Adults (18-65 years) Page 6 of 31 What the care home does well: What has improved since the last inspection? What they could do better: We looked at the risk assessment records for two residents, one individuals risk assessments were up to date and had been reviewed in May 2008. The other residents risk assessment had not been reviewed in over a year. we were told by the registered manager that there was no change to the assessment records and that she would make sure a review takes place imminently. We looked at the MAR sheet records of all four residents. One of the residents does not take their medication at the correct times or can refuse. The information should be written on the reverse of the MAR sheet record to inform of any changes in the prescribed routine. We were told by the registered manager that the GP and other professionals were aware of the issues and we looked at records to show what actions had been taken. We had a full tour of the home looking at the decoration and fixtures and fittings. We were shown by two residents their kitchen, the units are in a bad state of repair and do need replacing with a new kitchen. The residents told us that they want a new kitchen as it was not good. We went into one of the residents bedrooms and were shown cracks in the plaster that requires filling and also that the bedroom needs to be painted. We looked at the training records of all staff working at Percy Road. One member of staff has not completed all mandatory refresher training, we were told by the registered manager that the member of staff will not be a lone worker until the training has been completed. Care Homes for Adults (18-65 years) Page 7 of 31 We requested the training information on four regular bank staff sent to Percy Road. None of the staff had completed or were up to date with mandatory training, one individual had not completed the in house induction programme. The organisation must make sure that all staff sent to Percy Road have the relevant skills and are competent to do their job. We looked at the water temperatures for the home that were set at the correct temperature. The registered manager must also include the four residents hot water outlets in their bedrooms as part of the checks to make sure they are set at a safe temperature. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the the objectives and philosophy of the service supported by a service users guide. Evidence: We spent time looking at the registration certificate that is placed in the hallway by the front door, the registration certificate is accurate. We looked at the statement of purpose and service user guide, both documents were very informative about Percy Road and would inform prospective residents and family members of what the service aims and objectives are. The documents were seen in pictorial format, in discussion with the registered manager we were told that the documents can be produced in different formats and languages if requested. We looked in two residents files, each contained a needs assessment that was detailed and had a lot of information regarding the care required for each person. The care Care Homes for Adults (18-65 years) Page 10 of 31 Evidence: plans were then seen to work in conjunction with the initial assessment that show how the home is meeting all of the residents health and social needs. We spent time with residents and staff, all were seen to use the preferred method of communication for each of the four residents. We looked at the files of two residents and each contained a tenancy agreement that had in place all of the information about the care and support they would receive from the home. Each person had signed and dated the tenancy agreement, this document is renewed annually to include any changes including rent increases. The original contracts are kept at the Yarrow head office. Care Homes for Adults (18-65 years) Page 11 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plan is developed with the person using the service. The care plan is person centred and is based on a full holistic assessment. It includes reference to equality and diversity and clearly addresses and focuses on the individuals strengths and personal preferences. Evidence: Comments from people living at the home. I love living here at Percy Road. I like doing my PCP and looking at the pictures with my key worker. We looked at the care plans of two residents that are called Person Centred Plans, The PCP plans were very good showing how staff communicate with each resident in the way they prefer, using photographs, drawings and other forms of information Care Homes for Adults (18-65 years) Page 12 of 31 Evidence: gathering. We were shown a recent PCP on the computer of one resident showing their likes dislikes and what they are aspiring to achieve in the next six months. The PCP plans show how the staff are meeting the care needs of the residents, what their personal choice is and also what they dislike. We saw a lot of review records showing that the staff and residents use the PCP as an ongoing plan. We spent time in the communal areas of the home where staff and residents were going about their daily routines. Staff were seen to be communicating with each resident in the way they could understand, staff were not telling residents what to do but were supporting and informing residents about what they were doing including getting ready to go to a community activity. All of the residents are supported to be independent, all of the residents do make decisions regarding what they like to wear, on the day of this inspection two of the residents told us they had chosen their outfits and were wearing warm clothes as it was cold outside and they were going out. All of the residents are supported to participate in the day to day running of the home, one resident told us that they enjoyed helping to keep Percy Road clean and tidy and liked to hoover up. We saw information in the two PCP plans that show that the residents keep their rooms clean and tidy and have an allocated time to do their laundry. When we spoke to the residents they told us they are happy with their plan. We looked at the risk assessment information on two residents, one residents records were up to date and were reviewed in May 2008. The other resident had not had their risk assessment records reviewed in over a year. We discussed this with the registered manager who stated that she would make sure that the risk assessment review would take place immediately. We were told that the risk assessments had not changed and there was no new identifiable risk to the person. We looked at the care plans and records of two individuals that are kept in the staff office in the home, that is locked when no one is in the room. All other information is stored on the computer that all staff have to gain access by using a password. All staff have confidentiality training as part of the induction programme. Care Homes for Adults (18-65 years) Page 13 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team help with communication skills both within the service and in the community, to enable residents to fully participate in daily living. Evidence: Comments from residents and staff. I like to go out everyday, I go to college and I love to go dancing. I go to work and do two jobs and I would like another job. All of the residents are encouraged to go out into the community as much as possible. The residents have a varied activity plan that suits the individual and we support them Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: to do what they want to do. We spent time looking at Person Centred Plans that had been completed with the residents. The PCP plans show how residents are assisted to make decisions with lifestyle skills. All of the residents living at Percy Road require different levels of support, we saw staff liaising with the residents and confirming their activity programme for that day and evening. We looked at the PCP plans and activity programmes that show what individual does on a daily basis. Community links include attending college, going to the Gate for dance and drama, going to work and going out to local cafes. The activity programmes vary depending on what each person wants to do, three of the residents told us they go out as much as possible. One resident chooses not to participate in activitys a lot of the time and will stay in bed a lot. We were told by the registered manager that she has liaised with the persons psychologist and psychiatrist to see if they can assist in looking at the reasons for the residents behaviour. We looked at the two residents files that had in place their religious preferences, we were told by a member of staff that no residents attend any religious services at this present time. We looked at the visitors book that shows Percy Road does have family visiting on a regular basis. We were told by a resident that their family comes to see her a lot and they like visiting Percy Road. We were told by a member of staff and the registered manager that they encourage people to visit the residents, this includes family, friends and advocates. We spent time looking at daily menu plans and talking to the registered manager and residents. We were told that all staff attend food hygiene and nutrition training. a resident told us that the food was really good and that they enjoy choosing what to eat and sometimes will help to prepare the meals. All of the residents living at Percy Road are able to choose what they like to eat, one resident needs to have a specialised diet and information is in place to show what the resident can eat. We saw monthly weight charts for two residents and the registered manager told us that all four residents are weighed to make sure their weight is stable and also to monitor for signs of ill health. We looked at the finance records for all four people living at the home. All of the residents finances are kept in separate security tins and locked in the safe. Each resident has agreed that their money be kept by the home and given to them when requested. We looked at the financial transaction records showing all expenditures, three of the residents records were up to date and the balance was correct. One residents key worker was on annual leave and a message had been left by the registered manager for the staff member to complete the financial transaction record Care Homes for Adults (18-65 years) Page 15 of 31 Evidence: of a resident, to bring it up to date. Care Homes for Adults (18-65 years) Page 16 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have access to health care and remedial services. The health care records of the service are very informative and show that all residents health care needs are being met. Evidence: We looked at the PCP plans that show how residents are supported with personal care and health care needs. All of the residents living at Percy Road require different levels of support, from assisting to bath to checking with the resident that they have completed their personal care themselves. We saw staff assisting residents throughout this site visit, all support was provided in privacy. There is a walk in shower on the ground floor and a bath on the first floor, one of the residents told us that they enjoy both. We spent time looking at the health care plans of two residents. The information was up to date and relevant, each individual had records of up to date health checks that had taken place. All of the residents are registered with a local GP and have the full support of other health professionals in the community. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: We looked at the medication records MAR sheets of all four residents, each resident has their photograph and information at the front of the MAR sheet. One resident may refuse to take their medication at the prescribed time and then take it later in the day when they get out of bed. The registered manager has liaised with the GP and other health professionals to inform them of the current situation. The staff do fill in the MAR sheet however it shows a different time of the day, in discussion with the registered manager we discussed any information should be recorded on the back of the MAR sheet to show the reason for the change. The registered manager told us that she would liaise with all staff regarding recording any changes. All of the residents are assisted with their medication, the PCP and health care plans were very informative and show what the medication looks like and what it is for. Care Homes for Adults (18-65 years) Page 18 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. All of the staff working at the home are fully aware of the procedure to follow if a safeguarding incident occurs. There is a complaints procedure at the home that is known to residents and staff and is available on request in different formats and languages. Evidence: Comments from residents. I would talk to a member of staff if I was not happy. I would tell the manager if I was not happy. We spent time looking at the complaint procedures, there have been no complaints in the last 12 months. The complaints procedure is included in the statement of purpose and service user guide that are available in different formats. We spent time talking to the registered manager and staff who were knowledgeable about the organisations responsibility in responding to a complaint. We spent time discussing the safeguarding incidents at the home with the registered manager, all incidents were initiated because of a residents behaviour. The registered manager had followed the correct procedure and was working closely with the local Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: authority social worker. All relevant professionals were informed and the registered manager had put in place risk assessments and the appropriate monitoring action for all staff to follow. Care Homes for Adults (18-65 years) Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. Residents can personalise their rooms. They also say the home is clean, warm, well lit with sufficient hot water. Evidence: Comments made by residents. I really like living here and my bedroom is lovely. I like my bedroom, but it needs painting. The kitchen is not good and we need a new one. We spent time having a full tour of the home with one of the residents who told us that she is very happy living at Percy Road. We were shown by three residents their bedrooms, all of the bedrooms were very personalised with pictures, photographs and other personal items. We were told by all of the residents that they are happy with their rooms. One resident showed us the walls in their bedroom that required plastering and painting. We were shown the kitchen and two of the residents told us Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: that they are not happy with the condition of the kitchen and that a new kitchen should be fitted. The kitchen is in need of replacing as doors are now falling off and it looks unkempt. On the day of this visit the cooker and hob were being replaced as they had been condemned by the gas board. The home was very clean and tidy on the day of this site visit and we were told by a resident that they really enjoy helping doing the cleaning to keep the house lovely. Care Homes for Adults (18-65 years) Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The training provided is limited to bank staff with areas of training not being identified, and not being provided to make sure that all staff are competent in their roles. The training records for staff have not been up dated and the welfare of the people living at the home could put them at risk. Evidence: We spent time looking at the staff information on the AQAA document that was completed by the registered manager. We spent time talking to the registered manager and staff about their qualifications. Three of the five staff currently working at Percy Road have an NVQ qualification, we were told by the registered manager that the two remaining staff will registered in May 2009. We looked at the staff rota for February 2009 and there are adequate staff on duty for each shift. We were told by a member of staff that three of the residents go out most days to various activities, one resident is escorted by one member of staff and also collected at the end of the activity. Because of incidents with one residents challenging behaviour we were told by the registered manager that the staffing levels are increased when required to make sure all of the residents are protected. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: We looked at the CRB disclosure information for all staff working at the home including bank staff, all have an up to date disclosure in place. We did not look at any other recruitment records at the home as they are kept at the Yarrow head office. We spent time in December 2008 looking at staff files that had all of the relevant information in place. In discussion with the Human Resources manager we did discuss all references being validated, we were told that this is part of the recruitment procedure for all new staff. We spent time discussing training with the registered manager and staff and looking at training records. One member of staff has not had up to date refresher mandatory training including food hygiene, manual handling, medication or safeguarding. In discussion with the registered manager this member of staff will not be lone working until they have completed the training. We also requested the training information on four bank staff that work at Percy Road on a regular basis. None of the staff have completed all of the mandatory training and should not be sent to work at the home until they have done so. We received information from the organisation to show what bank staff have completed training and those that have not are not to be sent to placements until all training is up to date to protect the people using the service. We spent time discussing supervision and appraisals with the registered manager and staff. We were told that all staff are up to date with supervision, a member of staff told us that they get monthly supervision and that the registered manager has an open door policy that staff can request time with her when they need to discuss an issue. The registered manager told us that all staff are up to date with their supervision and annual appraisals. Care Homes for Adults (18-65 years) Page 24 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the necessary experience to run the home. They are aware of and the work to the basic processes set out in the NMS. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. Evidence: We spent time talking to the registered manager about their training programme. We were told that she does attend training on a regular basis to keep herself up to date. We discussed the Registered Managers Award qualification and was told that she has not yet yet got the qualification and has to register, the registered manager told us that the organisation is looking for a provider of the relevant qualification. The registered manager has worked for Yarrow for 13 years and has been the registered manager at Percy Road for 7 years. We spent time talking to a member of staff who was very positive about the support Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: from the registered manager, stating they could approach her at any time for assistance or advice. We saw the registered manager working along side staff being an inclusive member of the team. Throughout this site visit we spent time looking at different records, all of the records looked at were well written and up to date except for training for one member of staff and the four bank staff currently working at the home. The registered manager has implemented an action plan to nominate staff for the relevant training. We spent time liaising with the organisation and receiving information about bank staff training. All of the records are kept in the staff office that is lockable. All information on the computer is only accessible by a security password and we were told by the registered manager that all staff have a password. The quality assurance procedure for the home was looked at and questionnaires returned to the home in 2008 from residents, their families, advocates and other professionals were very positive about Percy Road. Yarrow organisation produces an annual summary for all of their homes that is available to all residents and any other stakeholders. We spent time with the registered manager looking at the health and safety records for the home. We looked at the fire risk assessments, fire tests and evacuation records, gas, electric and hot water temperatures. All checks are completed on a regular basis with records in place. The registered manager must include the residents bedroom hot water outlets as part of the weekly checks to make sure they are set at a safe temperature. As written in this report all staff must be up to date in health and safety training as some staff are not and a requirement has been made to meet this area to protect residents and the staff. Care Homes for Adults (18-65 years) Page 26 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 The registered manager must make sure that all residents risk assessments are reviewed at least annually. To safeguard the individual and show how a risk has been minimised with an action plan in place to inform staff. 12/03/2009 2 20 13 The registered manager must make sure that the back of the MAR sheet is completed when PRN medication given and when other information is written on the front of the MAR sheet. To show why the record does not match the original information and show the reason for the change. 12/03/2009 3 24 16 The organisation to replace 12/08/2009 the kitchen units as they are in a bad state of repair. Care Homes for Adults (18-65 years) Page 28 of 31 To provide a comfortable safe environment for the people living at the home. 4 26 16 The organisation to decorate 12/05/2009 a residents bedroom. To provide a comfortable environment for the individual. 5 35 18 The registered manager must provide all staff with mandatory training. To safeguard all of the people living at the home. 6 35 18 The organisation must 12/05/2009 provide all bank staff with a full training programme and not send to the home until mandatory training has been completed. To protect all of the people living at the home and to make sure all staff are competent in their roles. 7 37 9 The organisation must provide the registered manager with the relevant training to register and complete the Registered Managers Award. To make sure the registered manager is up to date in managerial competencies and appropriately qualified. 8 42 13 The registered manager 12/03/2009 must make sure that the hot water temperatures from outlets in all residents rooms is checked weekly. Page 29 of 31 12/05/2009 12/05/2009 Care Homes for Adults (18-65 years) To make sure the hot water is at a safe temperature to protect residents. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 31 of 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!