Inspection on 26/07/07 for Sach Road (31)

This inspection was carried out on 26th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sach Road (31) 26/10/06

Sach Road (31) 27/02/06

Sach Road (31) 08/12/04

Sach Road (31) 08/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Sach Road (31) 31 Sach Road Hackney London E5 9LJ Lead Inspector Rob Cole Key Unannounced Inspection 26th July 2007 10:00 Sach Road (31) DS0000010285.V346931.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 Sach Road (31) DS0000010285.V346931.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. Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sach Road (31) Address 31 Sach Road Hackney London E5 9LJ 020 8442 4253 020 8350 6723 sachroad@hotmail.co.uk 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 Nonoy G Capina Mrs Mina Joy A Capina Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 Brief Description of the Service: 31 Sach Road is a residential care home for five people with learning disabilities. The home comprises a two storey Victorian end of terrace property in a residential area in Clapton, in the London Borough of Hackney. The home is within walking distance from Lower Clapton Road, which has a parade of shops. Mare Street and Dalston shopping areas are accessible by transport links. The home is privately run. The current range of fees charged is between £600 and £1400 per person per week. Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 26/07/07 and was unannounced. The inspector had the opportunity of speaking with service users, staff from the home, and the homes manager was present for much of the inspection. The inspection also included an examination of records and other documents, along with a tour of the premises. The inspector was able to observe staff interactions with service users, which also provided evidence to support judgements made within this report. Prior to the inspection the home completed an Annual Quality Assurance Assessment at the request of CSCI, which was used as part of the overall inspection process. What the service does well: What has improved since the last inspection? What they could do better: Despite these improvements, there are still a number of issues that must be addressed, and the inspector was disappointed to note that the overall number of requirements set has risen from four at the last inspection, to eleven at this inspection, along with one good practice recommendation. Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 6 Areas that need to be addressed as a matter of priority include the training of all staff in adult protection issues and relevant health and safety matters. The home must ensure that clear systems are in place for monitoring service users finances to help reduce the risk of financial abuse, and comprehensive care plans must be in place for all service users to help ensure they receive consistent support as appropriate. 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. Sach Road (31) DS0000010285.V346931.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 Sach Road (31) DS0000010285.V346931.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): 1,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that prospective service users are provided with sufficient information about the home to enable them to make an informed choice as to move in or not. This information is provided through written documentation, and the opportunity of visiting the home. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The Statement says “The aim of the home is to engender a homely atmosphere where the residents enjoy a sense of security, and to meet the different needs of individuals while maximizing their potential for independence.” The Statement also includes details of the manager, staff team and their qualifications, the aims and objectives of the homes and the organisational structure of the home. The Service User Guide has been produced in a format which combines clear written English and photographs and pictures to help make it more accessible to service users, thus helping to meet their needs around equalities and diversity issues with regard to disabilities. The Guide includes details of the physical environment and of the homes complaints procedure. However, the Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 9 Guide is not fully in line with National Minimum Standards, for example, it does not include details of the fees payable, what they cover, and what is extra, and it is required that the Service User Guide contains all information required by the National Minimum Standards. Individual written contracts/statements of terms and conditions are in place for all service users. These have been signed by the service user and by a representative of the home. Contracts include details of the services and facilities provided. However, as with the Service User Guide, they do not include all relevant details of fees payable. There have been no new admissions to the home since the previous inspection, indeed, there have been no new admissions since 1998, and the current group of service users give the impression of been very settled at the home, and comfortable with each other. The home does however have an admissions procedure in place. This stated that pre admission assessments would be carried out on any prospective service users, and that they would have the opportunity of visiting the home before making a decision as to move in or not. Service users would initially move in to the home on a three month trial basis. There was evidence that the home is able to meet both the collective and individual needs of service users. Staff spoken to demonstrated a good understanding of service users individual needs, for example around equalities and diversity issues. For instance, one service user has autism, and staff were able to demonstrate a good understanding of this, and how it affected the everyday life of the service user. For instance, if any changes in routine were planned, such as a holiday away from the home, staff made efforts to ease any anxiety around this change by talking about it well in advance of the event, and explaining in detail what the change would mean in practical terms. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that service users have a large degree of control over their daily lives, it is required that comprehensive care plans are in place for all service users, to help ensure that the home is meeting all their needs in a consistent manner. EVIDENCE: Individual care plans are in place for all service users, but these are far from comprehensive. Care plans tend to concentrate on health needs, for example around needs associated with autism, epilepsy and medication. While these are clear and easy to understand, they do not cover other areas that the home provides support with. For example, the manager informed the inspector that two service users require high levels of support with their personal care, yet there were no care plans in place around this. Other areas of need, such as Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 11 around equalities and diversity issues, and social and leisure needs were also found to be missing from care plans. It is required that comprehensive individual care plans are in place for all service users, clearly setting out how the home is able to meet all of their assessed needs. Risk assessments are in place for all service users, and these were of a satisfactory standard. They included risks associated with healthy easting, using kitchen equipment and violence and aggression. Indeed, where service users have a history of exhibiting challenging behaviours, clear individual guidelines are in place around managing this. Assessments identify any potential risks, and include strategies to manage and reduce these risks. They make clear that service users are supported to take reasonable risks, and are subject to regular review. Through observation and discussion there was evidence that service users have a large degree of control over their daily lives. When the inspector arrived at the home, one of the service users was away on holiday, one was at home, while the other three were at various day services. When they arrived home they were able to inform the inspector that it was their choice to attend these services, and that they enjoyed going to them. Other areas where the inspector witnessed choice included times for getting up and over mealtimes. The service user who was home when the inspector arrived indicated that they wished to go out during the course of the inspection, and this was observed to be facilitated. Service users were observed to move freely around communal areas of the home. Service users informed the inspector that they are involved in the daily routines of the home, for instance cooking and helping to keep their bedrooms tidy. The manager informed the inspector that service users were involved in the day to day running and decision making of the home. For example, the home recently had a new kitchen fitted, and service users were involved in choosing this. There was evidence that regular service user meetings are held, these are minuted. The minutes indicated discussions around activities, holidays and meals. The Annual Quality Assurance Assessment (AQAA) provided by the home indicated that bedrooms have recently been rearranged in line with the wishes of service users. The home did not have a confidentiality policy in place. Furthermore, staff demonstrated only a limited understanding of the issues around confidentiality, for example they were vague around when a confidence may have to be broken in the health, safety and welfare interests of service users and others. It is required that the home has a comprehensive policy on confidentiality, and that staff have a good understanding of the relevant issues around confidentiality. Confidential records were however stored securely, and the inspector was informed that staff and service users could access their records as appropriate. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that service users are supported to live valued and fulfilling lives, and that they have regular access to the local community. EVIDENCE: There was evidence that service users have regular access to the community, to take part in a variety of social and leisure activities, day services and educational opportunities. Three service users attend a local college, two of whom take numeracy and literacy classes, while the other studies sculpture. Four of the five service users regularly attend day services most weekdays. Here they have the opportunity of engaging in various activities, including learning computer skills, cooking skills and gardening. The service user who is involved in gardening informed Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 13 the inspector that “I really like going to gardening.” Along with two other service users they are also involved in maintaining the homes own garden. Day services also provide service users with the opportunity of developing and maintaining friendships. Day services help service users access the local community, for example one service user is currently involved in a programme around the use of public transport. Day services also arrange day trips, such as to museums, and a recent trip to Madame Tussauds. The home also arranges various activities, which help to meet service users needs around social and leisure needs, along with equalities and diversity needs. For example, service users are supported to attend religious festivals, while two service users attend the Anika Patrice Project, which is for service users from ethnic minority backgrounds, where they are involved in various activities, such as an African music programme. Other leisure activities include trips to pubs, the cinema, yoga and the home arranges various day trips. Recent trips have included Southend, Legoland and Chessington World of Adventure. Service users routinely access other community facilities, including shops, markets, banks and the library. Service users are supported to go on holidays, in line with their choice. Service user meetings indicated that service users are involved in choosing and planning holidays. At the time of inspection one service user was on a walking holiday in Wales. It is planned that four service users will go to Paris in September. One service user is visiting the Dominican Republic to visit family members later this year. Service users have access to a variety of activities in house, such as foot spa’s TV, video, music and sensory sessions. The home also arranges occasional parties, for example to celebrate birthdays. The home has a visitor’s policy in place, which states that visitors are welcome at any reasonable time. Service users are able to receive visitors in private if they so wish. Service users maintain regular contact with their families, and are able to go for overnight stays. One service user was able to go to Cuba with their family to attend a family wedding. Service users are given their own mail to open, and have access to a telephone, which they can use in private. The home keeps records of menus, and service users informed the inspector that they are involved in choosing menus. One service user commented that “I can choose what I have for dinner.” The inspector was pleased to note that service users have worked with speech therapists to help provide skills around choosing their own menus, helping to meet equalities and diversity needs around disabilities, and to promote choice. Equalities and diversity needs are further met through the food provided, for example Caribbean and Chinese food is offered to service users from these ethnic backgrounds. The kitchen was clean and tidy, and food was stored appropriately. Records are kept of fridge and freezer temperatures, and service users were observed to be offered Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 14 drinks and snacks throughout the inspection. However, the inspector was disappointed to note that there was no fresh fruit available in the home. It is required that the home has plentiful quantities of fresh fruit available, to help meet the dietary needs of service users, and to ensure that they have a regular choice of healthy foods. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home is able to meet the personal care needs of service users, more must be done to ensure that their health needs are met, for instance ensuring that they have routine access to relevant health care professionals as appropriate. EVIDENCE: As mentioned already, two service users require high levels of support with their personal care, and this is not detailed within their individual care plan, which must be addressed. However, the manager informed the inspector that personal care was provided in a way that encouraged service users to manage their own personal care as much as possible, to help promote their independence and dignity. All service users are registered with a GP. Records are maintained of medical appointments, including details of follow up action required. Records indicated Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 16 that service users have had access to some health professionals, e.g. GP’s and opticians. However, two service users have not had any access to dental care in the past two years, and it is required that service users have routine access to all relevant health professionals as appropriate, including dental care. All service users have an annual review of medication in conjunction with their GP, and these feed into individual health action plans, which were of a good standard. These are drawn up with the involvement of health professionals, and clearly set out the health needs of service users, and how the home is to meet those needs. The home has a medication policy, however, this only covers the administration of medications. To help ensure that the home handles medications appropriately, it must have a comprehensive policy on the ordering, receipt, storage, handling, administration, recording and disposal of medications. Medications are stored securely in a locked cabinet inside the office. Staff are required to attend training before they are able to administer medications. No service users currently self medicate or are on any controlled drugs. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. The home maintains Medication Administration Record charts, those checked by the inspector were accurate and up to date. The home has sought and recorded the wishes of service users (or their family where appropriate) on the arrangements to be made in the event of their death. The manager informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the inspector was satisfied that the home has appropriate policies in place around complaints and adult protection, more still needs to be done to help ensure that service users are protected from the risk of abuse. For example, robust procedures must be in place around service users finances, and all staff must undertake adult protection training. EVIDENCE: The home has a complaints log in place, although the manager informed the inspector that the home has not received any complaints since the previous inspection. There was also a complaints procedure, this has been produced in written and pictorial form to help make it more accessible to service users, and to meet their needs with regard to equalities and diversity issues. All service users have been provided with their own copy of the procedure, and a copy was prominently on display within the home. The home has a copy of the Local Authorities adult protection procedure in place, and also its own procedure on adult protection. This appeared to be in line with current legislation. However, the manager informed the inspector that not all staff employed at the home have undertaken training in adult protection, and staff questioned by the inspector demonstrated only a limited understanding of their roles and responsibilities with regard to adult protection Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 18 issues. To help ensure that service users are appropriately safeguarded from the risk of abuse, it is required that all staff undertake adult protection training, and that they have a good understanding of the relevant issues involved. The home holds money on behalf of service users in a locked cabinet. Where service users are given their own money to spend, they are expected to sign to indicate they have received it. Where staff spend money on behalf of service users records and receipts are maintained of these transactions. Those records checked by the inspector appeared top be satisfactory. However, the inspector has concerns about the financial arrangements that are in place for one service user. This service user has a cash card so that money can be withdrawn from cash points. Staff hold this card on behalf of the service user, and whenever money is withdrawn, a record is maintained of this. However, the home does not receive any statements from the bank relating to this account, they are instead sent to a relative of the service user. This means that the home is unable to carry out any checks to ensure that all monies withdrawn are entered in the homes records as appropriate, thus potentially increasing the risk of financial abuse. To help ensure that service users are as free as possible from this risk, the home must introduce systems so that it can appropriately check that all monies withdrawn from the service users account are done so for the sole use of the service user. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. EVIDENCE: The home is situated in the Clapton area of the London Borough of Hackney, close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. The homes communal areas consist of a sitting room, kitchen/dining room, visitor’s room and a well maintained garden, with appropriate garden furniture. The home was generally well maintained, both internally externally. Furniture and fittings in the home were domestic in character, and generally well Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 20 maintained, although the sofa in the sitting room was coming towards the end of its useful life, and it is recommended that the home gives consideration to replacing this item of furniture, and that service users be involved in choosing any replacement. The home has one bathroom/toilet, one shower room and one two toilets on their own. The inspector was satisfied that the home has sufficient toilet and bathing facilities to meet the needs of service users. Bathrooms all had working locks fitted, which included an emergency override device. On the day of inspection bathrooms were clean, tidy and free from offensive odours, and all had soap and hand drying facilities as appropriate. All service users have their own bedrooms, which they have been able to personalise to their individual tastes, for example with televisions and family photographs. Bedrooms all have a hand basin in them. Bedrooms meet National Minimum Standards on size requirements, and have adequate natural light and ventilation. Central heating is provided in all bedrooms, and radiators had appropriate protective coverings in place. Bedrooms had appropriate furniture, including table and chair, chest of draws and a wardrobe. Curtains, carpets and bedding were well maintained and domestic in character. Bedrooms were clean and tidy on the day of inspection. The home has a separate laundry room, which has an impermeable floor covering. Laundry facilities were appropriate in scale for the home. Hand washing facilities were situated around the home, and to help prevent the spread of infection protective clothing such as gloves and aprons were available to staff. COSHH products were stored securely. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34 and 35. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although it is the view of the inspector that the home is staffed in sufficient numbers to meet the needs of service users, service users would further benefit from the staff team having appropriate training and qualifications in relevant care and health and safety issues. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. The home had a staffing rota on display, which accurately reflected the staffing situation on the day of inspection. Through observation and discussion there was evidence that staff are able to meet the collective and individual needs of service users. Two service users who were present during the course of the inspection have complex communication needs, including no verbal speech, and staff were able to demonstrate a good ability to communicate with them through the use of sign Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 22 language, for example service users were observed to make a sign that indicated they wanted a biscuit, and staff were observed to respond to this. Staff were observed to interact with service users in a friendly and respectful manner, and to be proactive in engaging service users in conversation. For example when one service user returned from day services, staff initiated a conversation about how their day had been, and what they had done, and it was evident that the service user was interested in this conversation and was happy to talk about their day. Service users informed the inspector that they liked the staff, and that they were treated well. Staff were able to demonstrate a good understanding of their roles and responsibility with regard to the provision of care, and all staff have been provided with a copy of their job description. The home has various employment related policies in place, for example on recruitment and selection, equal opportunities, grievance and disciplinary procedures. Staff employment records were checked by the inspector. These were found to be satisfactory, containing all necessary documentation, including proof of ID and CRB checks. Of the six care staff employed at the home, only two have successfully achieved a relevant qualification (although the manager informed the inspector that the other four are currently working towards such a qualification). It is required that at least 50 of care staff employed at the home have an NVQ Level 2 in Care or equivalent qualification. All staff undertake a structured induction programme, which covers service user issues, and includes shadowing more experienced members of the staff team. Recent staff training has included medication, end of life care and manual handling. However, staff have not had all necessary health and safety training, for example several staff have not had any recent training in fire safety, or food hygiene, even though they are involved in food preparation. To help ensure the health, safety and welfare of service users it is required that staff undertake all required health and safety training as appropriate. Sach Road (31) DS0000010285.V346931.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The inspector was satisfied that this is a generally well run home, and that the manager is suitably qualified and experienced. EVIDENCE: The homes manager is a registered learning disabilities nurse, who has thirty years experience of working in a care setting. They have successfully achieved the Registered Managers Award. Staff and service users were observed to interact with the manager in a relaxed manner, and service users informed the inspector that they found the manager to be approachable and accessible. Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 24 The inspector checked several of the homes policies and procedures, and while most were found to be of a satisfactory standard, including recruitment and selection and admissions, others were not satisfactory. As mentioned, the home does not have a clear policy on confidentiality, and the medication policy needs much development before it is in line with National Minimum Standards. It is required that the home has in place all policies and procedures required by the Care Homes Regulations 2001 and the National Minimum Standards. Record keeping was generally satisfactory, although as mentioned, some rerecords, including care plans, need further development. Fire extinguishers were situated around the home, these were last serviced on the 9/10/06. The home tests fire alarms on a weekly basis, and alarms were last serviced on the 21/3/07. The home holds regular fire drills, and a fire risk assessment has been carried out. The home had in date safety certificates for gas safety, PAT testing and electrical installation. Hot water and fridge/freezer temperatures are tested as appropriate, and COSHH products were stored securely. The home has in date employer’s liability insurance cover in place. Sach Road (31) DS0000010285.V346931.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 2 2 X 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 3 2 3 3 3 Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 26 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18 Requirement The registered person must ensure that at least 50 of the care staff employed at the home achieve an NVQ Level 2 in Care or equivalent qualification. (Timescale 28/03/07 not met) The registered person must ensure that the homes Service User Guide contains all information required by National Minimum Standards, including details of the fees charged by the home, what they cover and what is not included in the fees. The registered person must ensure that comprehensive individual care plans are in place for all service users, covering all areas of need, including needs associated with personal care, and equalities and diversity issues. The registered person must ensure that the home has a clear policy in place on confidentiality, which includes details of when a confidence may be broken in the health, safety and welfare interests of service users and others, and that all staff have a DS0000010285.V346931.R01.S.doc Timescale for action 31/12/07 2. YA1 5 30/09/07 3. YA6 15 30/09/07 4. YA10 13 30/09/07 Sach Road (31) Version 5.2 Page 27 5. YA17 16 6. YA19 13 7. YA20 13 8. YA23 13 9. YA23 13 and 16 10. YA35 18 11. YA40 17 good understanding of the issues involved around confidentiality. The registered person must ensure that fresh fruit is routinely available in the home, to help provide service users with a choice of healthy and nutritious foods. The registered person must ensure that service users have access to all relevant health care professionals as appropriate, including dental care. The registered person must ensure that the home has a comprehensive policy in place on the ordering, receipt, storage, administration, recording and disposal of medications. The registered person must ensure that all staff undertake training in adult protection issues as appropriate. The registered person must ensure that appropriate systems are in place to monitor any monies spent by or on behalf of service users to help ensure that they are not at risk of financial abuse. The registered person must ensure that all staff undertake all necessary statutory health and safety training as appropriate. The registered person must ensure that the home has all necessary policies in place, in line with the Care Homes Regulations 2001 and the National Minimum Standards. 31/08/07 30/09/07 30/09/07 31/10/07 31/08/07 31/10/07 30/09/07 Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 28 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 YA24 Good Practice Recommendations It is recommended that the home gives consideration to the purchase of a new sofa for the lounge, and that service users are given the opportunity of choosing this sofa. Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sach Road (31) DS0000010285.V346931.R01.S.doc Version 5.2 Page 30 - 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!