Inspection on 28/01/08 for Sahara Lodge

This inspection was carried out on 28th January 2008.

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 17 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 25/09/06

Sahara Lodge 21/02/06

Sahara Lodge 13/10/05

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 Lea Alexander Unannounced Inspection 28 January 2008 10:30 th Sahara Lodge DS0000022847.V355327.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 Sahara Lodge DS0000022847.V355327.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. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 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 vacant post Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 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. 25th September 2006 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. 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. The home’s current fees range from £950 to £1,200 per week after which there are individually assessed specialist fees. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of two days. In addition an “expert by experience” also visited the home. The expert by experience is an independent person with experience in the field that is able to give the Inspector their view of the service provided. During the course of the inspection the Inspector and expert by experience spoke with staff and people who use the service. The Inspector also met with the Manager and examined paperwork and documentation relating to the running of the service. This included resident’s personal files and staff personnel files. This is a report about 143 Earlham Grove, a care home for adults with learning disabilities. An Inspector and an “expert by experience” visited the home and spoke with people who live there and with staff. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 6 What the service does well: Residents told the expert by experience that that they liked the staff and got on well with them. Each resident has his or her own plan that is updated regularly. Residents take part in activities inside and outside of the home. Residents stay in contact with their families. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 7 Residents help choose the meals. Staffs help residents to look after their personal care. Residents have their own bedrooms that they personalise how they want to. There are regular, permanent staffs that receive training. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? Resident’s plans have got better. The back garden is secure. Some residents have support 24 hours each day. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 9 The homes records are kept in good order. The staff rota is easier to understand. What they could do better: Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 10 The home must complete their own assessment before people move in. Care plans should contain enough information, and be signed by the resident. Care plans should include information on how residents are supported to make decisions. Possible risks should be assessed. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 11 The activities provided should be more person centred. A variety of meals should be provided. All residents should be supported to attend healthcare appointments. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 12 All medication should be stored safely. The home must make sure it listens to residents. The home must make sure that people who use the service are safe. Some repairs and maintenance work needs carrying out. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 13 Staff should have some specialist training. A permanent manager should be employed. Some health and safety practises need improving. 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. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 14 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.V355327.R01.S.doc Version 5.2 Page 15 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has developed a statement of purpose and obtains assessment information from other professionals. EVIDENCE: The home has produced a statement of purpose. The Inspector noted that this accurately reflected the situation found within the home, however the term “person centred” was used throughout the document, but this was not reflected in the plans viewed by the Inspector. One person who uses the service has moved to the home since the last key inspection. The Inspector sampled their personal file. This evidenced that a copy of the local authority Care Management assessment had been obtained. It was not however evidenced that the home had carried out its own assessment of need prior to the resident moving in. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 16 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person who uses the service has his or her own plan, and this is regularly reviewed. However, a risk assessment was not available for all residents and it is not clear how people who use the service are supported to make decisions. EVIDENCE: The Inspector sampled the personal files for two people who use the service. Each had individual plans that addressed a range of personal, social and healthcare needs. The Inspector noted that some plans could be more detailed to address issues such as communication. For example, one person who uses the service does not speak. Their communication plan detailed how they would communicate that they were hungry or sad, but did not contain information on how they might communicate emotions or other needs. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 17 Based on the plans seen, the Inspector was of the view that the home should develop these to be more person centred. The Manager told the Inspector that they were introducing a new tool “listen to me” tool to develop the homes individual plans and make them more person centred. The plans seen by the Inspector were found to include details of the tasks required by the care worker, however they were not signed by the resident or their representative to evidence their participation and agreement with the plan. The individual plans for one person who uses the service were evidenced as being reviewed at least every six months. The second resident had been living at the home for less than six months and there had been no changes in need, so their plans had not yet been reviewed. Neither of the care plans sampled by the Inspector addressed issues of the person’s ability to give informed consent when presented with choices, and this is an area that requires development. Everyone who uses the service have their own bank or building society account or have an independent appointee that looks after their money. People who use the service receive help in managing their finances. This includes help in withdrawing cash from the bank or building society and having a personal allowance held by the home that residents can access when they need to. The home maintains a record of all monies received by people who use the service and withdrawals. Since the last inspection an anonymous complaint was received regarding the management of service users finances. As a result the London Borough of Newham carried out its own investigation and conducted several strategy meetings. The Inspector attended several of these meetings and also received copies of the findings of the local authorities investigations. These evidenced poor recording and accounting of service users personal allowances. The home acknowledged shortfalls in its practise and as a result some unaccounted monies were reimbursed to service users and the homes accounting practises and procedures have been reviewed and revised. Sampling of records relating to the personal allowances of people who use the service during this inspection evidenced that new practise for recording and managing residents finances have been introduced. The home has also employed independent auditors to review the homes financial practises. The records sampled by the Inspector for two people who use the service during this inspection evidenced that the home maintains a record of the date and nature of each transaction that is signed by a staff member. Receipts for purchases are also retained. The monies available for two residents were found to correspond with the amount recorded in their individual logs. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 18 The Inspector noted that a recent transaction was recorded for a contribution to a fellow residents birthday gift. However, it was not evidenced how the person who uses the service had consented to this arrangement. For one of the residents case tracked a range of comprehensive risk assessments addressing a range of potential risks and hazards had been completed and regularly reviewed and updated. For the second case tracked resident no risk assessment was available on the personal file. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 19 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are given opportunities to participate in a range of activities and in the day-to-day running of the home. Residents are also supported to maintain contact with their families. However, the home needs to develop a more individualised approach towards activities for residents, and ensure that a varied menu is provided. EVIDENCE: Discussion with the Manager, their deputy, people who use the service and sampling of individual plans evidenced that people who use the service are engaged in a range of community and leisure activities. Four people who use the service regularly attend a day service. Some residents attend the local Gateway club each Tuesday evening. The home also has a programme of daily Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 20 activities that includes bowling, golf and lunches out. Some people who use the service had also been on a recent day trip to the seaside. Within the home there is a television and stereo, and the deputy manager told the Inspector that some residents enjoyed arts and crafts activities. In the garden there is trampoline and football equipment. Some residents told the expert by experience that they enjoyed playing football in the garden, another resident told them that they enjoyed growing their own vegetables in the homes garden. The Inspector examined the individual plans for two people who use the service. One-person lives in a self contained flat adjacent to the main home. In the leisure and activities section of their plan it was recorded that the person liked listening to music and attending the local park. There was no other information recorded about past activities or interests. The Inspector examined the daily log for this resident for the previous three months and this evidenced they had participated in two day trips, and had been bowling or to golf on a total of three occasions. They had also been out for their lunch on five occasions with other residents. There was also evidence of regular visits to the local park. On most days the resident was recorded as having listened to music, although the Inspector noted that only three CD’s were available in their flat. The resident also frequently visited the main house to watch TV or have meals with other people who use the service. For the second resident case tracked by the Inspector their individual plan recorded that they attended a day service five days per week, but no other information relating to community or leisure activities was recorded. The expert by experience observed staff interacting with people who use the service and noted that on occasion a resident was presented with a cookbook by a staff member and asked if they would like to bake a cake. The resident chose the cake they wanted to make, but were then told by the staff member that this was too difficult. The resident chose another cake and was told that the right ingredients were not available. It was unclear whether the resident was later supported to go the shops to buy the necessary items and then make the cake. Whilst people who use the service engage in a range of community and leisure activities case tracking evidenced the need for the home to develop more individualised, person centred activities. Discussion with the Manager, Deputy, people who use the service and sampling of individual plans evidenced that residents are supported to maintain contact with their family. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 21 During the course of the inspection staff were observed interacting with residents, and residents were observed to choose when to be alone or in company. Discussion with the Manager, Deputy and people who use the service evidenced that residents and staff meet each week to discuss the menu and choose the meals for the coming week. Pictures are used to support residents to make informed choices. The Inspector viewed the homes log of meals provided and noted that in a five-day period pies or pasties were recorded as being provided on four occasions. One resident who was case tracked by the Inspector was evidenced as having their lunch out on six occasions between the 9th and 24th January 2008. On each occasion the lunch had been purchased from their own monies, in accordance with the homes policies and procedures. The Inspector noted that the foods purchased on these occasions tended to be fried foods of a similar nature. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 22 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 & 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs promote privacy and dignity whilst supporting residents with personal care. However, the home must support all residents to access healthcare services and address some shortfalls in its medication practise. EVIDENCE: The Deputy Manager told the Inspector that four residents require practical assistance to maintain their personal care, and the remainder require prompts or reminders. At the time of this inspection the home employs two male carers. The Inspector was advised that a female carer could always attend to female residents, but that male residents could not always have their personal care attended to by a male care worker. The Inspector observed that the residents at home during their visits appeared well groomed. Sampling of the individual plans for two residents evidenced that these included guidance on supporting residents to choose their own clothes and appearance. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 23 The Inspector interviewed one of the care staff on duty. They were able to describe the practical steps they take to promote resident’s dignity and respect during the provision of personal care. People who use the service told the expert by experience that their daily routines were flexible. Sampling of the personal file for one person who uses the service evidenced that they had been supported to access a range of healthcare services. The date, type of appointment and the outcome were recorded. For a second person that uses the service that moved to the home some months ago there was no record of healthcare appointments. The home has produced a medication policy and procedure. This includes guidance to staff on the administration and recording of drugs. It also makes appropriate reference to controlled drugs. One person who uses the service is currently prescribed a controlled drug. The Inspector noted that these are delivered from the pharmacy in large blister packs that do not fit inside the homes controlled medicines cupboard. In the adjacent basement flat, the Inspector noted that the medicine cupboard had been left with the key in its lock. The Inspector viewed the Medication Administration Record (MAR) sheet and compared this with the actual medication available in the medicines cupboard. For both residents the MAR sheets were in good order. For both people who use the service all of the available medications were listed on the MAR sheet, however for one resident an “as required (PRN)” medication that was listed on the MAR sheet was not available. The personal file for one person who uses the service was found to contain a statement of their wishes in the event of illness dying or death, but this was not available for a second resident. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 24 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, but some residents do not know how to access it. Staffs have received safeguarding training, however some shortfalls in the homes safeguarding practises have been identified. The home has acknowledged this and has developed an action plan to address these. EVIDENCE: The Inspector viewed the homes complaints policy. This includes the timescales within which the home aims to deal with complaints. The Inspector also viewed the homes complaints log. The last recorded complaint occurred in 2004. The expert by experience and the Inspector observed that copies of the homes complaints procedure were not available in a picture, or easy read format. The expert by experience spoke to one resident who told them that they were not sure what their rights were or what to do if they were unhappy. The home has developed an adult protection policy and procedure. This includes definitions of abuse and descriptors of the types of abuse vulnerable adults may experience. The policy makes appropriate reference to local safeguarding multi agency protocols. The Inspector spoke with one care worker on duty, and they demonstrated a sound awareness of the types of Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 25 abuse vulnerable adults may experience, and their responsibilities should they have any adult protection concerns. As stated earlier in this inspection report, a number of anonymous adult protection allegations have been made regarding the management of resident’s findings. Several strategy meetings were held and an audit undertaken. This highlighted poor recording practises with regards to resident’s monies. The home has produced its own action plan to address identified shortfalls, including its own audit, revision of policies and procedures and staff training. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a comfortable home. However, floors and surfaces should be regularly cleaned and a range of maintenance and repairs need addressing. EVIDENCE: The home is situated in a large terraced property in a residential area with close proximity to local shops and amenities. A one bedroom self-contained flat is located in the basement of the adjacent house. This flat was viewed by the Inspector and expert by experience and found to be in a poor state. Identified maintenance works are listed in the requirements section of this report. The Inspector and expert by experience also toured the main accommodation. The main house has a large lounge and dining area with a kitchen off. There is Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 27 also a laundry room and access to a large rear garden. A small telephone room is also located on the ground floor. Service users bedrooms are located on the ground, first and second floors, and there are bathrooms on the ground and first floor. A small staff office is located on the ground floor and the manager’s office is located on the first floor. A staff sleep in room and additional storage space are located on the top floor or the home. People who use the service told the expert by experience that they had their own room keys, and that they could personalise their room to reflect their own personality. One resident’s bedroom had recently been refurbished. The accommodation provided is generally homely and comfortable, however some kitchen surfaces and appliances and bathrooms would benefit from cleaning. The tour of the premises also identified a range of maintenance and repair issues that are detailed in the requirements section of this report. The home was found to be free from offensive odours. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffs are supported to undertake external qualifications and are provided with core training. The homes recruitment practises protect people who use the service. EVIDENCE: The Manager advised the Inspector that the home has a complement of twelve care workers, some of who also work at other homes owned by the organisation. The Inspector was advised that ten support staff have obtained NVQ level 2 with some care workers now studying for NVQ level 3. The Inspector examined the homes current staffing rota. This has been revised to include a key for the codes used in the rota. The staffing situation found in the home reflected that found on the rota, and it also evidenced that 1:1 support was provided to one resident on a 24 hour basis, as identified in their plan. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 29 The Manager told the Inspector that the home does not currently have a process whereby people who use the service can be involved in staff recruitment, and that this was something that would be developed. The Inspector sampled the personnel files of two care workers. This evidenced that two satisfactory references and an enhanced level Criminal Records Bureau check had been obtained for each prior to their taking up their employment. Copies of their employment terms and conditions were also found on file. The Inspector found a completed induction record on each of the personnel files sampled. The Inspector viewed the training records for two staff that currently work at the home. This evidenced that since the last inspection they had completed training in food hygiene, first aid, health and safety, medication, adult protection and fire safety. The Manager told the Inspector that a new programme of challenging behaviour training would be provided to staff in the next year. The home does not at present provide specialist learning disability training to staff, and the Manager advised the Inspector that they hoped to develop this. Supervision records for a long standing member of staff were not available at the time of the inspection and the Inspector was therefore unable to evidence the frequency of supervision provided, however, during discussions the staff told the Inspector that they did receive regular supervision. A new member of staff was evidenced as having received supervision on one occasion in the month since taking up their post. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 & 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally has good health and safety practises. However, there is no permanent manager in post and no recent quality assurance exercise. EVIDENCE: The previous registered Manager left the home in October 2007. At present a Deputy Manager from one the organisations other homes is the acting manager for this and a second Sahara home. The Responsible Individual advised the Inspector that they had advertised and interviewed for the Managers post without success and were now considering permanently appointing the acting Manager and considering what support and development they might need to fulfil the role. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 31 The acting Manager has completed NVQ level 3 and has previously worked within the organisation as a Deputy Manager. They have several years experience prior to this as a support worker. The Manager advised the Inspector that whilst questionnaires asking for feedback had been sent out in previous years, a quality assurance exercise had not been carried out for 2007. The records sampled by the Inspector were generally found to be in good order. The home maintains a daily record of fridge and freezer temperatures. The Inspector viewed these, and the recorded temperatures were found to be within acceptable limits. The Inspector also viewed the homes fire records. These evidenced that weekly fire alarm call point tests are carried out, and the results recorded. The home maintains accident and incident records. These were viewed by the Inspector and found to be in order. The expert by experience viewed the contents of the home fridge and noted that some started processed foods and prepared items had not been date labelled. During the tour of the premises the expert by experience and the Inspector noted that the second floor fire escape was sloped and that potentially hazardous broken glass and bricks were found on the fire escape steps. The home displayed a current insurance certificate at the time of this inspection Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 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 2 23 2 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 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 2 2 X 2 X 3 2 3 Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? Yes. 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. 2. Standard YA2 YA6 Regulation 14 15 Requirement New service users must only be admitted on the basis of a full assessment. The service users or their representatives must sign all care plans. This is a restated requirement. The previous target of the 16/12/06 was not met. Individual plans should contain sufficient information relating to the needs of people who use the service, for example how they communicate. The home must demonstrate 30/06/08 how individual choices have been made; and record instances when others have made decisions and why. Potential risks identified in the 30/06/08 individual plan must be appropriately risk assessed and a management strategy developed. The home must develop more 30/06/08 individualised person centred activities for people who use the DS0000022847.V355327.R01.S.doc Version 5.2 Page 34 Timescale for action 30/05/08 30/06/08 3. YA7 12 4. YA9 13 5. YA14 16 Sahara Lodge service. 6. YA17 13 & 16 When service users purchase their own meals the reasons for this should be clearly recorded in the daily log. 30/05/08 7. YA19 12 8. YA20 13 The home should ensure that varied and nutritious meals are supplied. The registered person ensures 30/06/08 that the healthcare needs of people who use the service are recognised, and that procedures are put in place to address them. All prescribed medication, 30/05/08 including PRN medications must be available. Controlled drugs must be stored in accordance with the current regulations and guidance issued by the Royal Pharmaceutical Society of Great Britain. The Manager must ensure that signed statements are obtained from each service user or their representative concerning their views and requested arrangements in the events of ageing, illness or death. This is a restated requirement. The previous targets of the 05/05/06 and 16/11/06 were not met. The home must ensure that there is a clear and effective complaints procedure that residents know how to access. The home must implement its action plan to safeguard people who use the service. In the basement flat the following repairs and maintenance must be carried out: (i) In the lounge the Version 5.2 Page 35 9. YA21 12 30/06/08 10. YA22 4 & 22 30/06/08 11. 12. YA23 YA24 13 13 & 23 30/06/08 30/06/08 Sahara Lodge DS0000022847.V355327.R01.S.doc (ii) (iii) (iv) broken chair, coffee table and picture frames must be replaced. In the bathroom the missing wall tiles and broken toilet seat must be replaced. Missing skirting boards in the hallway must be replaced. In the bedroom the curtains must be properly hung. In the bathroom and shower room in the main house the following repairs and maintenance must be carried out: (i) (ii) (iii) (iv) Vents and extractors must be cleaned. Broken shower hoses must be replaced. The marked shower seat must be replaced. More appropriate storage must be found for mops and cleaning equipment. Broken toilet seats must be replaced. Damage side panels by the side of the bath must be replaced. All sinks must be fitted with plugs. Non-slip shower mats must be provided. Shower curtains must be cleaned or replaced. The damaged ceiling must be repaired. Version 5.2 Page 36 (v) (vi) (vii) (viii) (ix) (x) Sahara Lodge DS0000022847.V355327.R01.S.doc (xi) Suitable locks that can be overridden in cases of emergency must be fitted to bath and shower room doors. In the lounge area in the main house the damaged radiator cover must be repaired or replaced. In the kitchen in the main house: (i) (ii) The work surfaces and appliances must be cleaned after use. The floors must be cleaned regularly and kept free from foodstuffs. In the laundry room in the main house the following repairs and maintenance must be carried out: (i) The cupboard containing potentially hazardous cleaning materials must be repaired so that its contents are secure. The laundry room would benefit from re-organization and storage to prevent it being overcrowded and cluttered. (ii) In the main house cracked glass in one fire door must be replaced. The homes floors and carpeting must be regularly cleaned. Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 37 13. YA35 18 14. 15. 16. YA36 YA37 YA39 12 & 18 8&9 24 17. YA42 12 & 37 The home should provide specialist learning disabilities training to enable staff to better meet the needs of people who use the service. The manager must ensure that supervision records are available for inspection. The home must appoint a permanent manager who must undergo the registration process. The home must obtain the views of residents, their families and other interested parties on the service provided. Outcomes from this quality assurance exercise must be collated and published. All started processed foods or prepared meals must be date labelled. The homes fire escapes must be safe to use. 30/09/08 30/06/08 30/06/08 30/06/08 30/05/08 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.V355327.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 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 Sahara Lodge DS0000022847.V355327.R01.S.doc Version 5.2 Page 39 - 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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