Inspection on 13/10/05 for Sahara Lodge

This inspection was carried out on 13th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sahara Lodge 28/01/09

Sahara Lodge 28/01/08

Sahara Lodge 25/09/06

Sahara Lodge 21/02/06

Sahara Lodge 05/07/04

Sahara Lodge 17/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Sahara Lodge 143 Earlham Grove Forest Gate London E7 9AP Lead Inspector Nurcan Culleton Unannounced Inspection 13th October 2005 10:00 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sahara Lodge Address 143 Earlham Grove Forest Gate London E7 9AP 0208 555 3735 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) Sahara Homes (UK) Limited Ms Sharon Kaur Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registration inclusive of basement flat at 141a Earlham Grove The home can accommodate one (1) named service user over the age of 65 years. 2nd December 2004 Date of last inspection Brief Description of the Service: Sahara Lodge is run by Sahara Homes (UK) Limited and is registered to provide accommodation, care and support for nine people with learning difficulties. It consists of two separate units, a semi-detached care home for eight service users and an adjacent basement flat accommodating one service user. Sahara Lodge is aimed at service users with learning disabilities who may also have challenging behaviours. It provides twenty-four hour supervision and support in a secure and safe environment. The basement flat is provided with the same level of twenty-four hour support by staff from the care home. This includes one wake-in and one sleep-in member of staff at the care home and flat respectively. Sahara Lodge is close to local amenities including a park, shops and leisure services. Forest Gate station is close by and there are good bus routes to Stratford. The Provider, Sahara Homes (UK) Limited, also owns two other homes in East London for people with learning disabilities, Shrewsbury Road and Cranbrook House. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 13th October 2005. The Manager and Senior Care Worker assisted the inspector. At the time of inspection, there were five service users in the house. Some service users had gone to day centres and one had a medical appointment. Three staff members were on duty. The findings in this report follow the examination of records by the inspector, including service users’ and staff files in the home; a tour of the premises and interviews with two service users, two staff members and the Manager. This inspection also reviewed the requirements given at the announced inspection of 05th July 2004. What the service does well: What has improved since the last inspection? What they could do better: There are 12 requirements in total, 6 of which are restated and out of these, 4 requirements have been restated in two previous inspections. This shows a lack of commitment and action to meet regulatory requirements and is a matter of concern. Requirements relate mostly to inadequate documentation and records kept in the home, most significantly for example, the lack of integration of risk assessments with care plans, which could adversely affect the care and support offered to services. The quality of these assessments must improve. The Provider and Registered Manager must be advised that action is required to address all requirements within the timescales specified in this report and that further non-compliance is likely to lead to enforcement action. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 6 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. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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): 1, 2, 3, 4, 5 Prospective service users’ needs are assessed. The home demonstrated its capacity to meet assessed service users’ needs. Service users lack the information entitled to them concerning the home’s services and facilities, as according to regulation. EVIDENCE: Service users’ needs are assessed according to the homes’ admission criteria and assessments by the Local Authority and the home were available in files. Prospective service users are able to visit the home prior to admission. The home showed its capacity to meet assessed needs through records kept in service users’ files, the knowledge, skills and commitment shown by staff and in the ongoing development of service users in the home. The inspector viewed the Statement of Purpose and Service Users’ Guide. The Registered Manager has failed to ensure that these documents contain all information required by regulation, as listed in Schedule 1. This requirement has been restated in the inspections of 26/10/03, 17/03/04, 05/07/04 and is restated again in this inspection. Similarly, the requirement to update the service users’ contract to contain all required information is also restated. This document must include the terms and conditions of placement; the method and payment of fees and the provision of services and facilities. Compliance is now required to meet all previous requirements. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 9 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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, 8, 9, 10 Service users are supported to take risks as part of an independent lifestyle, are consulted on and participate in all aspects of life in the home. Care plans and risk assessment documents need more work to ensure that needs identified in assessments and care plans are clearly identified and integrated. EVIDENCE: Evidence seen demonstrates that the home supports service users with their personal development. One service user was supported to make tea for the inspector. Another service user washes their own clothes. Some service users buy newspapers in the mornings. Service users’ meetings take place monthly where their views are expressed and taken into account. Positive statements by service users were expressed in minutes of these meetings, ie “..likes the house/meals/ staff and likes going to church..” Individual care plans seen in files covered a broad range of service users’ needs: daily living activities; social and family relationships; personal development and independent living skills; accommodation; cultural and spiritual needs; financial needs and mental and physical health. Each area of need is outlined on a separate page and reviewed respectively at the back of each page every month. Risk assessments were also examined. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 11 Several risk assessment documents were seen in each file examined and were confusing in their presentation, for example, some risks identified in one document were missing in another, with a lack of clarity as to whether previously identified risks were still relevant or had not reviewed. In the case of one service user, their care plan specified that they could be violent and had attacked staff and service users. This did not follow with actions identified in the risk assessment to minimise this risk. The care plan also lacked sufficient detail as to how to deal with this behaviour, or lacked reference to consult the professional guidance available in the file for this behaviour management. The review format at the back of the assessed needs in the care plan must also be improved, for example it lacked a review of mental health needs. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 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): 11, 12, 13, 14, 15, 16, 17 Service users have opportunities for their emotional and personal development and the development of their social and community skills. EVIDENCE: Records of activities examined in service users’ files evidenced that service users are supported to exercise their independent living skills where capable, as in their participation in cooking; shopping; laundry; washing up and in their personal care. Service users are encouraged to develop their social and communication skills, with support for the particularly vulnerable from the Community Team for people with Learning Difficulties. Service users attend different day centres and a club for people with learning difficulties, according to their assessed needs. Other service users who have declined such activities are encouraged to engage in other social and community and activities inside and outside of the home. These include golf, going to the cinema, meals and drinks out to a restaurant or pub; trips in the minibus and visits to church. Inside the home there are various activities such as arts and crafts and pampering offered by staff. Contact and visits with family and friends is encouraged. Risk assessments were viewed in relation to key holding. The menu is planned with service users and the menu consisted of varied and nutritious food. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 13 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, 21 Service users are supported to maximise their personal development with dignity and respect and their physical, mental and emotional health needs are met. Medication practises are safe, however an outstanding requirement regarding medication policy is restated. A policy on ageing, illness and death is also outstanding. EVIDENCE: Service users interviewed confirmed that they are treated well and with respect. Staff were knowledgeable in the support needs of individual service users and demonstrated appropriate interaction showing sensitivity and respect to service users. Files contained correspondence and reports from multi-disciplinary professionals through the local health services and Local Authority, including professional assessments and health appointments. Staff also complete weight and menstruation monitoring charts. The consultant psychiatrist reviews Service users with behavioural or emotional needs. Medication administration and records were checked and deemed to be correct at the time of inspection. A restated requirement on 05th July 2004 for the medication policy to include the need to retain medication for seven days in the event of death is outstanding. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 14 A restated requirement made at the inspection of 5th July 2004 to develop a policy and procedure for addressing ageing, illness and death of service users is also outstanding. These policies must now be in place. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 15 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 Service users know how to complain and feel their views are listened to and taken seriously. Service users benefit from staff who are knowledgeable in Adult Protection matters. EVIDENCE: There were no recorded complaints since the last inspection. The staff informed that service users were satisfied with the home and that no complaints had been expressed. This view was supported by documents and minutes of meetings seen by the inspector and by positive statements provided by service users directly. The complaints policy is satisfactory and also produced in pictorial form. The Adult Protection policy is satisfactory and staff interviewed confirmed they had received training on adult protection. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 16 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, 25, 26, 27, 28, 29, 30 Service users benefit from living in a homely, comfortable and safe environment, which is suitable to meet their needs. EVIDENCE: Service users live in a comfortable, clean and homely environment. Service users’ rooms were furnished with personal items such as photographs, pictures, furniture. There are sufficient toilet and bathroom facilities. There is a combined lounge and dining room with a large television and 3 sofas. The inspector also viewed the kitchen and laundry room and garden, which was well designed with a patio, table and chairs. A requirement is given for decoration to the walls in the hallway which require repair. . Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 17 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): 31, 32, 33, 34, 35, 36 Service users benefit from staff who are clear on their roles and responsibilities and who are well trained and knowledgeable in responding to their needs. Service users benefit from staff who are provided with management support and training to assist in their service delivery. EVIDENCE: A requirement was issued at the inspection of 5th July 2005 for staff files to contain all necessary information. Three staff files were inspected. Two staff files contained all documentation as required by regulation. One staff file lacked proof of identification with a photograph, a statement to confirm physical and mental health medical fitness and a CRB. The Manager informed that this staff member had transferred from another of the Sahara homes and that her documentation was likely to be there. The Commission must be satisfied that all staff have all the necessary documentation as listed in Schedule 2. Staff interviewed confirmed that they receive good supervision and support from their manager and regular training. There are thirteen permanent staff members and one just recruited. There are sufficient staff numbers to meet the needs of the service users, with two to three staff members on duty during the day to a maximum of five service users; one wakeful and one sleepin staff member in the main home and additional wakeful and sleep-in staff overnight in the adjacent flat. Staff receive induction and most staff have or are doing an NVQ Level 2 or 3. The senior care worker acts as a deputy in the absence of the Manager. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 18 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): 40, 41, 42 Service users benefit from good health and safety practises within the home and their rights and best interests are safeguarded by the homes’ policies and procedures. However water temperatures need to be adjusted and a water safety certificate is required. EVIDENCE: The Registered Manager was not available during this inspection. Some records required by regulation and as described in the report are still outstanding and must be in place in the home. The home holds most of the policies and procedures specified in Appendix 3 of National Minimum Standards. Staff spoken to informed that they were familiar with policies and procedures. Health and safety certificates were examined. Fire equipment was tested on 10/03/05. Public Liability Insurance is valid until 31/03/06. The PAT test was due on 05/11/05. The Gas Safety certificate was dated 05/07/05. Other health and safety practices are observed, such as fire drills, water temperature tests, fridge and freezer temperatures. Requirements are given for a water safety certificate and for the water temperatures tested in wash basins to be adjusted close to 43 degrees, as the water was cold at the time of inspection. Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 19 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 3 3 1 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 3 1 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sahara Lodge Score 3 3 3 1 Standard No 37 38 39 40 41 42 43 Score x x x 1 3 1 x DS0000022847.V258131.R01.S.doc Version 5.0 Page 21 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 YA1 Regulation 4, Sch 1 Requirement The Registered Manager must ensure compliance with the restated requirement to update the Statement of Purpose to contain all necessary information outlined in Schedule 1. Timescales of 31/03/04 and 05/07/04 not met 2 YA1 5 The Registered Manager must ensure compliance with the restated requirement to update the Service Users Guide to contain all necessary information outlined in Regulation 5. Timescales of 31/03/04 and 05/07/04 not met. The Registered Manager must ensure compliance with the restated requirement to update the Service Users Contract to contain all necessary information outlined in Standard 5. Timescale of 05/07/04 not met. 4 YA6 15 The Registered Manager must ensure that service users’ care DS0000022847.V258131.R01.S.doc Timescale for action 10/02/06 10/02/06 3 YA5 17 (2), Sch 4 (8) 10/02/06 10/02/06 Sahara Lodge Version 5.0 Page 22 plans clearly outline all actions identified to meet each assessed service users’ need. 5 YA6 15 All needs identified in care plans with associated risks must be linked to a risk assessment with the action identified to minimise the risk, and vice versa. The Registered Manager must ensure that risk assessment documents used in service users’ files are clear. The medication policy must be expanded to include that medication must be retained for 7 days in the event of a service users’ death. Timescales 05/07/04 not met. The Registered Manager must ensure that the home has in place a policy on ageing, illness and death of service users. The timescales of 31/03/04 and 05/07/04 are not met. 9 YA24 23 (2)(b) The Registered Manager must ensure that redecoration of all walls in the hallway requiring repair. The Registered Manager must ensure that there is evidence of documentation available for all staff, as listed in Schedule 2. The timescales of 31/03/04 and 05/07/04 are not met. 11 YA42 13 (4)(c) The Registered Manager must ensure that a water safety certificate is available. 10/02/06 10/02/06 10/02/06 6 YA9 13 (4) 10/02/06 7 YA20 12 (1) 10/02/06 8 YA21 12(1) 10/02/06 10 YA34 19 (1) 10/02/06 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 23 12 YA42 13(4)(c) The Registered Manager must 10/02/06 ensure that water temperatures are adjusted close to 43 degrees. 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 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection East London Area Office Gredley House 1-11 Broadway Stratford London E15 4BQ 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 Sahara Lodge DS0000022847.V258131.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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