Inspection on 11/07/06 for Roland Residential Care Home (Hampden Way)

This inspection was carried out on 11th July 2006.

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

Other inspections for this house

Roland Residential Care Home... 24/11/05

Roland Residential Care Home... 27/01/05

Roland Residential Care Home... 05/11/04

Roland Residential Care Home... 20/01/04

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

CARE HOME ADULTS 18-65 Roland Residential Care Home (Hampden Way) 163 Hampden Way Southgate London N14 7NB Lead Inspector Peter Illes Key Unannounced Inspection 11th & 13th July 2006 09:50 Roland Residential Care Home (Hampden Way) DS0000010540.V298107.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 Roland Residential Care Home (Hampden Way) DS0000010540.V298107.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. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roland Residential Care Home (Hampden Way) Address 163 Hampden Way Southgate London N14 7NB 020 8368 1323 020 8882 7973 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 Dushmanthe Srikanthe Ranetunge Mrs Josette Esther Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user, who is over 65 years of age, may remain accommodated in the home. This condition must be reviewed at such time as the service user is discharged and the Commission of Social Care Inspection notified. One specific service user, who has a diagnosed enduring mental disorder and a mild learning disability, may remain accommodated in the home. This condition must be reviewed at such time as the user is discharged and the Commission for Social Care Inspection notified. 14th March 2006 2. Date of last inspection Brief Description of the Service: 163 Hampden Way is a home registered to accommodate seven younger adults with a diagnosis of mental disorder. The home was registered in September 1990 and is one of four residential care homes belonging to Roland Homes, a company owned by Mr and Mrs Ranetunge. The home is a three-storey semi - detached house, which has recently been extended. On the ground floor there is a kitchen, a lounge/dining room and two bedrooms. One of the bedrooms has an en suite toilet. On the first floor there are three bedrooms, a toilet and a shower room. The second floor consists of a loft extension. There are two bedrooms and a bathroom on the second floor. There is a building in the garden at the rear of the premises, which contains an office, lounge (with kitchenette facilities, laundry room and toilet. The home is located in a quiet residential area, near Southgate. There are a variety of shops, restaurants and other community facilities within a quarter of a mile of the home. The home currently charges from £675 per week depending on the assessed needs of the service user. Information, including the contents of CSCI reports are available to stakeholders and a copy of the latest CSCI report is kept in the home’s lounge. The aim of the home is to provide high quality care and support to service users and to promote and maximise their independent living skills. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection visit to the home was on the 14th March 2006. This was a brief visit and primarily involved a discussion with the registered provider. The previous inspection to that took place on the 24th November 2005 and included inspecting the majority of the key standards. The November 2005 inspection is referred to as the last main inspection in this report. This unannounced inspection took approximately seven hours over two days and all the key standards were assessed. Seven service users were accommodated at the home at the time. The lead inspector was accompanied and assisted by Ms Angela Hunt, regulation manager, for the majority of the inspection. For ease of reading the remainder of this report both the lead inspector and the regulation manager are described as “the inspectors” The registered manager was on annual leave at the time. Mrs Ranetunge was present for the majority of the inspection; one of her roles is service manager for the provider organisation. For the brief periods Ms Ranetunge was not present she helpfully arranged for managers from two other registered homes in the organisation to be available to give information and to generally assist the inspectors as required. The inspection included: meeting and speaking to the service users, five of them independently; discussion with the service manager; discussion with two other managers from the provider organisation and discussion with six staff, two of them independently. Further information was obtained from a tour of the premises and documentation kept at the home. What the service does well: The home provides good quality care and support to service users that have complex needs in ways that they appreciate. There are effective systems in place to regularly review service users needs with them and good quality records in place to assist staff in helping to meet these needs. The home works hard to assist service users maintain and develop their independent living skills. Staff said that morale in the home was good. Evidence was seen of meaningful and regular liaison between staff and managers from the home and provider organisation with health and social service staff from external agencies. The home has good quality monitoring systems in place to assist improve the service on an ongoing basis. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 6 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. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.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 Roland Residential Care Home (Hampden Way) DS0000010540.V298107.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users can be confident that their needs will be fully assessed and agreed with them prior to admission to the home to enable these to be effectively addressed when they move in. Once admitted service users needs are reassessed regularly, on a multi-disciplinary basis, to assist the home continue to meet their changing needs. EVIDENCE: No new service users had been admitted to the home since the last inspection. Three service user files were inspected at random and these contained a range of assessment information that was available to the home when each of them was first admitted. Evidence was also seen that the home introduces prospective new service users to the home appropriately with introductory visits and an overnight stay as part of the process. The files showed evidence that service users needs are reviewed on a three monthly basis by the home. There was also evidence of regular multidisciplinary joint reviews. These are held between the home and external health and social care professionals including the service user’s social worker, community psychiatric nurse and consultant psychiatrist as appropriate. Evidence was seen on the files inspected that service users were involved in their reviews. It was noted that one service user had annotated the record of a Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 9 recent review to ensure that it reflected their views to their satisfaction. Service users spoken to confirmed that they were present at their reviews, both internal and those including health and social care professionals and indicated in various ways that they were engaged in the process. The inspectors were informed that some service users accommodated at the home are subject to after-care arrangements under current mental health legislation. This legislation is to ensure that health and social care agencies work in partnership using care planning approach (CPA) arrangements to provide services to people who have been discharged from hospital. Evidence was seen from the service users files inspected that joint working between the agencies was taking place although the review records seen were not formally titled as “CPA” review meetings. The service manager stated that the home had enquired about this from the Mental Health Trust in whose area the home is situated. She went on to say that the Mental Health Trust had informed the home that it did not use review records with this title albeit the legislation was being complied with. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users assessed and changing needs are well documented in their care plans to assist the home’s staff and relevant others in meeting these needs. Service users are assisted to make as many decisions for themselves as they can to promote their independence. Service users are also supported to take appropriate risks in their lives to assist them to safely achieve their aspirations. EVIDENCE: Care plans for three service users were inspected. These were detailed and showed evidence of significant staff input to ensure that the objectives agreed were being monitored. Elements of the care plans seen included clear guidance for staff on how to meet a range of needs including: self care and appearance, domestic skills, daily living skills, communication, social skills and personal relationships. They also included other elements as appropriate relating to individual service users needs. The home operates a key worker system and records were seen of regular key worker sessions on the files. Evidence was seen that the plans were informed by up to date risk assessments. Care plans seen were being reviewed on a three monthly basis with evidence that they Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 11 were updated as required to reflect any changing needs of the service user. Evidence was also seen that service users were involved in the reviews of their care plans and service users spoken to confirmed this. The inspectors were informed that a main objective of the home was to promote service users independence, assist them to gain or regain daily living skills and to develop their confidence in using these. Staff were observed interacting with service users in appropriate ways to assist in this process throughout the inspection. Any restrictions on service users were recorded on their files with evidence that these had been discussed with the service user and the restriction monitored at reviews. Examples seen of this included limitations on one service user going out unaccompanied in the community and of appropriate guidance and support being in place for another service user regarding personal relationships. Service users are encouraged to manage their own finances as far as possible with one service user spoken to confirming they managed their own finances. The home safeguards money for some service users and this is held in individual bank or post office accounts. Where service users cash is held for them in the home it is kept in individual moneyboxes locked in the office. The cash and records for one service user’s money were inspected at random and were satisfactory. Clear risk assessments were seen on service user files inspected. These were of good quality with guidance for staff on how to minimise the identified risks. Evidence was seen that the risk assessments were reviewed regularly with service users being involved in the process. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Service users enjoy a range of appropriate activities including both in-house activities and activities within the community. Contact with relatives and friends is maintained and encouraged in accordance with the service users wishes. Service users rights and responsibilities are respected and promoted within their daily lives. Service users also enjoy balanced and varied meals that meet their needs and preferences. EVIDENCE: One service user attends a local college and another a day centre each week, both service users travel independently to these. The service user that attends the day centre was spoken to independently and indicated that she liked the centre and felt she got a lot out of attending. All of the service users have an activity plan for the week and copies of these were seen in two of the service users rooms. Activities include a range of opportunities to develop independence skills including domestic tasks such as shopping, cooking and laundry. The inspectors were informed that one service user that is keen to Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 13 move on to more independent accommodation shops for their own food and is assisted in cooking it. The service user confirmed this. Service users are encouraged to access the local community including shops and other leisure and recreational activities. One service user told the inspectors that they had previously lived in Finchley in North London and enjoyed going out with staff to visit the area. Another service user told the inspectors that they enjoyed going swimming and they travelled independently on public transport. All the service users are of white European ethnic origin and the inspectors were informed that two of them were Catholic. The service manager stated that service users are supported to attend church or other places of worship if they wish and that their wishes are respected if they do not. Service users also enjoy social events facilitated by the provider organisation. One service user told the inspectors of a recent BBQ and party held at the provider organisation’s newly opened residential home. The inspectors were also informed that the provider organisation organises holidays and that those service users that wished to attend enjoyed a four day trip to Birmingham in June 2006. The service manager informed the inspectors that some service users had relatives that they kept in contact with to the extent that they and their relatives wished. Other service users had no family or had no contact with them if they did. Service users spoken to confirmed this. One service user spoken to independently was keen to move on to more independent accommodation and share that with a friend. There were multi-disciplinary records seen in the home that included how the service user was being supported in relation to this aspiration. The inspectors were informed that the home actively supports service users maintain and develop a range of appropriate relationships. However, individual support is offered to minimise the risk of service users being inappropriately exploited. Service users have keys to their bedrooms. One service user told the inspector that they had a key but chose not to lock their bedroom door. Service users were seen to come and go as they pleased throughout the inspection including using the tea and coffee facilities available in one of the lounges. Staff were seen to interact with service users appropriately and treat them with respect and dignity throughout the inspection. One service user spoken to independently stated that staff were “OK” and another spoken to independently indicated that staff were helpful especially when the service user was not feeling well. One service user was keen to tell the inspectors about their cat, named Pretty, and that the cat had now been adopted as the home’s pet. The home has a smoking policy that includes that service users are allowed to smoke in one of the home’s two lounges but not in the other. A menu for meals in the home was seen that included a range of healthful and varied meals. Staff stated that the menu was reviewed at monthly service user meetings and changed according to service users preferences. Records of Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 14 service user meetings were inspected and evidenced this. One service user has a separate menu that they shop for themselves as part of their preparation to move on to more independent accommodation. The inspectors were informed that none of the service users accommodated required a special diet. All of the service users spoken to indicated that they enjoyed their meals at the home. The home had a satisfactory stock of food that matched the menu, was within its use by dates and was appropriately stored. Records of health and safety checks in the kitchen were seen and were satisfactory, these included a hazard analysis chart, records of fridge and freezer temperatures and temperature checks of food when cooked. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive appropriate personal support in accordance with their needs and preferences. Their mental and physical healthcare needs are met including through referrals to a range of community based health professionals as required. Service users are also protected by clear polices and procedures regarding medication and its administration. EVIDENCE: The majority of service users need some assistance regarding their personal care, mainly in the form of verbal prompts. Guidance for staff on how this should be given is recorded in service users care plans and in other documentation on their files. Service users spoken to indicated that staff prompted them in an appropriate manner. At the last main inspection a requirement was made for staff to encourage an identified service user to wear a dressing gown over their nightclothes when they were seated in communal areas. The service manager stated that this had been raised with the service user as required. It was noted however that the service user still chose not to wear a dressing gown on occasion when they first got up, especially when the weather was hot. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 16 Healthcare needs were well documented in the review information and care plans seen. Evidence was seen that service users are registered with a local GP and individual files recorded that different service users have access to a range of appointments with external health care professionals. This included contact with their: GP, dentist, optician, community psychiatric services, therapy appointments, and a range of general outpatient appointments at a local hospital. The medication and medication administration record (MAR) charts for three service users were inspected and were satisfactory. A letter was seen on one service user’s file authorising for their medication to be crushed at the time of administration. A recommendation was made at the last main inspection that medication supplied in blister packs start at the same time of the week to avoid the possibility of an error occurring. The inspectors were informed that this was not appropriate as some service users had specific medication prescribed following blood tests and this needed to be prescribed as required. This meant that the blister packs could not necessarily all start on the same day of the week. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and others are able to express their views and concerns and have these appropriately dealt with by the home. Service users are also protected by a robust adult protection policy and procedure that staff are aware of. EVIDENCE: The home has a satisfactory complaints procedure. The complaints log was inspected and the last complaint recorded was on 19/10/05. A detailed recording was seen of this including the nature of the complaint, to whom the complaint was reported to, the appointed investigating manager, action taken, conclusion including whether the complainant was satisfied, this was signed by the service user and the complaint had been signed off by the investigating manager. Service users spoken to stated that they knew who to complain to and indicated that they believed that concerns or complaints raised are dealt with properly by the home. The home has a detailed and satisfactory adult protection procedure that was inspected. Evidence was seen that this had been reviewed since the last main inspection. This was to ensure that it was up to date and complied with the overall local authority adult protection procedures for the local authority that the home is situated in. The policy included the action that that staff should take in the event of an allegation or disclosure of abuse being made to them. It also clearly stated that staff should not investigate the allegation or disclosure further before it had been reported to the local authority and action agreed with them on how to proceed. Evidence was seen that staff had signed a Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 18 record to indicate that they had read the home’s procedure and evidence was also seen that staff had undergone training in adult protection. Staff spoken to confirmed this. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that is comfortable, well decorated, well maintained and meets service users needs although an identified area of maintenance needs attention. The home was clean and tidy throughout creating a pleasant environment for both those that live and work at the home as well as for those that visit it. EVIDENCE: The home is a three-storey semi - detached house that has additional accommodation built at the end of the rear garden. On the ground floor of the main building there is a kitchen, a lounge/dining room and two bedrooms. The additional building to the rear comprises a second lounge with kitchenette facilities, laundry, office and a toilet. One of the bedrooms has an en suite toilet. On the first floor there are three bedrooms, a toilet and a toilet/ shower room. The second floor consists of a loft extension that contains two bedrooms and a bathroom. One inspector undertook a tour of the building that included all the communal facilities and was also shown two of the bedrooms by the service users that occupied them. The home was seen to be comfortable and met the needs of the current service users. Service users spoken to confirmed this. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 20 The home was, clean and tidy throughout. The registered manager explained that any maintenance or other work needed was recorded in a maintenance book and was dealt with by one of the provider organisation’s handy persons. Staff spoken to independently confirmed that maintenance issues identified were dealt with promptly when reported. However, it was observed that there was a noticeable bulge in one corner of the kitchen ceiling from which paint had started to peel, that needed attending to. The inspector was informed that this had been identified by the home to be repaired. Despite this a routine requirement is made regarding the ceiling, as in the inspector’s judgement, it was a potential health and safety hazard in a kitchen. A requirement was made at the last inspection that a review of the use of the lounge in the house as a route to the new building takes place. The service manager stated that this had been complied with including ensuring that service users had appropriate privacy as required. A good practice recommendation had been made at the last main inspection that a ramped walkway is gritted in icy conditions to prevent accidents. The service manager stated that grit was available in the winter period. At the last inspection a good practice recommendation had been made that the home reviews the need for a washing machine with a sluicing cycle for washing soiled laundry. The inspectors were informed that this had been complied with and the laundry facilities were judged satisfactory for the needs of the current service users. The laundry facilities were inspected and the washing machine seen to have a 90º wash cycle. Staff were able to describe satisfactory infection control procedures. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent and effective staff team are deployed in sufficient numbers to properly address service users needs. A robust recruitment procedure contributes towards service users protection although further attention is needed in one identified area. Service users are also supported by staff who are appropriately trained and supervised to assist them further in meeting service users needs and in their own personal development. EVIDENCE: Staff are based at one of the four provider organisation homes although may work shifts at the other homes if required. A requirement had been made at the last main inspection that 50 of staff whose names appear on the rota for Hampden Way must have achieved national vocational qualification (NVQ) level 2 or 3. The service manager confirmed that over 50 of the provider organisation’s staff had achieved NVQ level 2 and also that some had achieved level 3. Evidence to support this was seen on staff files inspected and from staff on duty spoken to independently during this inspection. One of the two care staff on duty for the majority of the inspection had achieved NVQ level 3 in care. The staff rota was inspected and showed: two care staff on early shift, two care staff on late shift and one sleeping-in care staff at night. The registered Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 22 manager’s working hours are in addition to this. The staff on duty during the inspection matched those recorded on the rota. Staff meetings take place every two months and records to evidence this were seen. Two care staff were spoken to independently. One had been in post for six months and stated that they had received appraisals after one month and three months in post. The other staff member stated that they received regular supervision. Both staff felt that they were well supported both formally and on a day-to-day basis. They both stated that they felt staff morale at the home was high and that staff from all ethnic groups were effectively supported. One member of staff stated that, “things get done quickly if we talk to managers”. Three staff files were inspected at random and indicated that the provider organisation operates a robust recruitment procedure. All staff files showed satisfactory proof of identity, criminal record bureau (CRB) checks and protection of vulnerable adults (POVA) clearances for staff recruited after July 2004. All three staff files contained two references. However, one of the files contained two personal references and not a last employer’s reference. The staff member’s application form gave details of a previous employer. The service manager indicated that checking last employer references was a normal part of the home’s recruitment procedure and acknowledged this as an oversight. A requirement is made regarding references. Evidence was seen that the home runs a good quality induction programme. The service manager stated that the induction programme was being further revised and improved to reflect the latest Skills for Care training organisation’s good practice guidance. Staff spoken to stated that they found the induction training they received as being clear and useful. A staff training plan for 2006/ 07 was seen that had been agreed with Barnet Further Education College. This identified staff training needs and how they were to be met through the coming academic year. Evidence of a range of staff training was seen on staff files inspected and from independent discussion with staff. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the home being effectively managed by the registered manager with clear direction and monitoring by the provider organisation’s service manager. Service users also benefit from the homes quality assurance system that incorporates their views on the service. Effective health and safety procedures contribute to protecting service users, staff and visitors to the home. EVIDENCE: At the last main inspection a requirement was made that the new manager of the home forwards an application to the CSCI to become the registered manager and this had been complied with. The registered manager was on annual leave during the inspection and both the service manager and staff spoken to independently spoke positively about her management style. The registered manager has completed her Registered Managers Award. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 24 The home operates an effective quality assurance system to assist review and improve the service. An annual quality assurance questionnaire had been distributed in October 2005 to service users and outside agencies. Returned questionnaires were sampled and showed a range of positive feedback. The service manager stated that overall feedback was given to service users and staff at respective service user and staff meetings. Objectives were then agreed to further improve the service as appropriate. The inspectors were pleased to be informed that the service manager visits the home regularly on an unannounced basis, often several times a week. This is to monitor the running of the home and the support and care being offered to service users. It was noted that the home now has a registered manager and a separate service manager and registered provider. Because of this, and to comply with regulation 26 of the Care Home Regulations 2001, a requirement is made that the registered provider must ensure that a monthly written report is sent to the CSCI regarding the overall running of the home. A range of satisfactory health and safety documentation was inspected that included: a gas safety certificate, electrical installation certificate, portable appliance testing as well as servicing and testing of the home’s fire fighting equipment and fire evacuation procedures. Satisfactory records were also seen of accidents in the home and that the home had a current public liability insurance certificate. Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 25 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 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 3 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 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 26 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 Service manager(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2) Requirement The registered persons must ensure that the kitchen ceiling is repaired to avoid it becoming a health and safety hazard. The registered persons must ensure that a verified reference is received from the last employer of any new prospective staff member as part of the home’s recruitment procedure. The registered provider must ensure that a monthly written report is sent to the CSCI regarding the overall running of the home. Timescale for action 31/08/06 2. YA34 19(1) 31/08/06 3. YA39 26 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Roland Residential Care Home (Hampden Way) DS0000010540.V298107.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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