Inspection on 28/01/09 for Sahara Lodge

This inspection was carried out on 28th January 2009.

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 28/01/08

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 19/06/2009.

CARE HOME ADULTS 18-65 Sahara Lodge 143 Earlham Grove Forest Gate London E7 9AP Lead Inspector Lea Alexander Unannounced Inspection 28 January 2009 1.30 th Sahara Lodge DS0000022847.V374492.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.V374492.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.V374492.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) maria.dziedziurska@saharahomes.co.uk Sahara Homes Limited Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Sahara Lodge DS0000022847.V374492.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. 28th January 2008 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.V374492.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector visited the home over the course of an afternoon and evening. We met with the Manager and also spoke with a care worker and several residents in the home. We also looked at paperwork relating to the running of the home including service users personnel files, staff personnel files and health and safety records. The home completed and returned its Annual Quality Assurance Assessment within the required timescales. The quality rating for this service is * stars. This means people who use the service experience adequate quality outcomes. What the service does well: We spoke with three residents who told us that they are “happy in the home” and “got on well with staff”. One resident told us that they hoped to move to more independent accommodation. During the course of our inspection we observed carers engage residents in a range of activities. The residents appeared happy and comfortable within the home. The home develops individual plans with each resident that are regularly reviewed. Residents are encouraged to manage their own finances, and where they are not able to appropriate support is provided. The home maintains records of all financial transactions. Residents have monthly meetings to discuss issues about the home. Some residents are involved in meaningful community activities. Residents are supported to maintain contact with their families. Residents help choose the weekly menu and enjoy the meals provided. Care workers promote dignity and respect whilst assisting with personal care. Resident’s appearance reflects their personalities. The home has developed complaints and safeguarding policies and procedures. Care staff have received safeguarding training and demonstrated a sound understanding of their role and responsibilities. People who use the service benefit from a comfortable, generally well maintained environment. Each resident has their own bedroom that they can personalise. Staffs are employed in sufficient numbers and are supported to undertake NVQ qualifications. Appropriate insurance cover has been obtained. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Three requirements from earlier inspections are restated. The home should develop more personalised community based activities for each resident based on their individual interests and abilities. All prescribed medication, including PRN medications must be available. The home must implement its action plan to safeguard people who use the service. As a result of this inspection an additional ten requirements are made: Where the home places restrictions upon individual choice the reasons for this must be clearly documented. When such restrictions impact upon other residents the home must evidence that appropriate consultation has taken place. The home must maintain a record of all healthcare appointments attended along with their outcome and any follow up. Where self-medicating residents become non-compliant with their prescribed medication the home must take appropriate, timely action. The home must establish a complaints log, where the date, nature of the complaint, details of the complainant and the investigation undertaken, outcome and actions taken are all recorded. The home should develop and implement an improvement and refurbishment plan for resident’s bedrooms. The home must be free from offensive odours. All staff must be evidenced as receiving at least five days training per year. The home must ensure that staffs receive regular supervision, a minimum of six each year. The homes Manager must commence the registration process with the Commission for Social Care Inspection. Outcomes from the homes annual feedback surveys from residents and other stakeholders must be collated and published. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 7 The home must carry out and record weekly fire alarm call point tests. The home must carry out regular fire evacuation drills and record these along with the time taken to complete the drill. The home must maintain a record of temperatures for all refrigerators and freezers, and this must be available for inspection. One good practise recommendation is also made as a result of this inspection: The home should ensure that life story work which includes significant events, relationships and educational and occupational achievements should be included in individual residents plans 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.V374492.R01.S.doc Version 5.2 Page 8 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.V374492.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service. The home has developed a statement of purpose that is specific to the individual home and resident group. Potential new residents are fully assessed prior to their moving in. EVIDENCE: Previous inspections have evidenced that the home has produced a statement of purpose and service users guide. We looked at the statement of purpose during this inspection and found that it had been updated to reflect the appointment of the new Manager. We examined the personal files for two residents. These evidenced that the home assesses potential service users prior to their moving in. Sahara Lodge DS0000022847.V374492.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individual plans are written in plain language and are easy to understand. The home also assesses potential risks relating to the individual plan. There is some evidence that residents are involved in the decision making processes of the home, however, where limitations on choice have been imposed it is not evidenced that consultation or agreement have been obtained. EVIDENCE: We looked at the personal files of two residents. This evidenced that the home develops individual plans with each resident that address a range of personal, social and healthcare issues. We noted that since the last inspection the home has introduced a new format for these plans. We found the format to be comprehensive and easy to follow. One of the resident’s files we looked at had Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 11 been recently admitted to the home. After looking through their plan and comparing it with information available from other sources, we thought that the plan could have more information about the residents support networks and personal relationships. The other resident has been living at the home for some time and more detailed, person centred information was included in their plan. This second resident was also evidenced as having their plan reviewed on a monthly basis. During our inspection of the home we noticed that a combination lock had been fitted to the kitchen door, and that this was in use. We asked the Manager about this and were told that a resident has diabetes and needs to monitor their food intake. However, they were not compliant with their dietary regime and often took extra foods from the kitchen. The Manager told us that to ensure the wellbeing of this resident the lock had been fitted to ensure that residents could not enter the kitchen without staff being aware. The provider subsequently told us that the lock had in fact been fitted as a service user had broken into the home and caused a flood in the kitchen when staff and residents were out. We were also told that the lock was only put into operation when all staff and residents were out of the home. It was unclear why different information was provided to us at the time of the inspection. We did note however that the lock was in use during our site visit. Whatever the reason for the fitting of the lock we were concerned to note that no risk assessment had been completed for this resident addressing this need. During our site visit we asked the Manager whether the introduction of the lock had been discussed and agreed with other residents, as it also restricted their access. We were told that it had been discussed and agreed at a residents meeting. We asked to see the minutes of this meeting, but these could not be located. We spoke to several residents and none could recall being consulted about the introduction of the lock to the kitchen door. The Manager told us that people who use the service have varying abilities and receive different support in managing their finances. One person who uses the service has their own bank account that they manage independently. Three other residents also have their own bank accounts and receive some support in managing their finances. Two residents have family members who manage their finances on their behalf, and two residents have appointees within the Social Services Department who manage their finances for them. We looked in detail at the financial support being offered to two residents at the time of this inspection. With the residents agreement the home holds in a safe a small amount of their cash to cover incidental expenses. The home maintains a notebook with a record of the date, amount and nature of each transaction. Receipts for each transaction were also available. The financial Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 12 records we saw were in good order with appropriate expenditures. The home also maintains a file relating to all financial correspondence, such as bank statements and Benefits information. We looked at the minutes of residents meetings. This evidenced that monthly meetings are held within the home that all residents are invited to attend. At recent meetings it was evidenced that activities, maintenance issues and holiday arrangements had all been discussed. On both of the personal files we examined a range of risk assessments had been completed addressing potential risks identified in the care plan. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 13 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, 15, 16 & 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some residents are involved in meaningful daytime activities of their choice. The home provides a variety of nutritious meals. People who use the service are supported to maintain family relationships. However, more consideration must be given to resident’s individuality and personal preferences with regards to community and occupational activities. EVIDENCE: Two people who use the service attend East Ham College twice per week for Music and Art sessions; a third resident attends these same sessions less regularly. A fourth resident attends a day service 5 days each week. A fifth resident is able to access the community independently, and we were told that this person spends much of the day visiting their partner who lives nearby. A Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 14 sixth resident receives 1:1 support on a 24-hour basis. We were told that the two remaining residents do not have structured educational or occupational activities. However, the home organises lunch out every Wednesday and a bowling or golf afternoon each Tuesday that all residents are encouraged to attend. We formed the view that residents in the main care home would benefit from more personalised, individual activities in the community. Residents are encouraged to attend the Gateway Social Club each Tuesday evening and Bubble disco each month should they wish to do so. During the course of our visit to the home we observed residents engaged in games activities with the carers on duty. We were also told that two residents visit local shops each day to purchase papers and magazines. The home accommodates male and female residents with a wide range of ages and from diverse cultural backgrounds. The Manager told us that the home aims to meet resident’s cultural needs through the provision of culturally appropriate meals and individualised activities. Some residents are also supported to attend church, should they wish to do so. We looked at the individual plans of two people who use the service. One residents plan contained information about activities they enjoyed, such as the trampoline, swimming and going for walks. The other resident’s plan identified that they spent much of their day visiting their partner. The Manager told us that each resident had their own activity plan, however we were unable to locate this on the personal files we examined and were therefore unclear as the frequency or duration of the activities identified in the plan. The majority of residents are in regular contact with family members. One resident frequently visits their family home, whilst other residents are more likely to receive visits from family members at the residential home. During the course of the inspection carers were observed interacting with residents, who were able to choose whether or not to join in an activity and whether to be alone or in company. The Manager told us that the residents meet once every week on a Sunday to choose the meals to be provided for the coming week. Care staff use pictures to support residents to choose meals, and the final menu is also displayed in a pictorial format. We looked at the homes record of meals provided, and found that these were varied and nutritious. The residents we spoke to told us that they enjoyed the meals provided. Sahara Lodge DS0000022847.V374492.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some resident’s healthcare needs are addressed in their individual plan. However, for other residents the home does not adequately record or monitor healthcare appointments. In some instances health care issues are not adequately recorded in individual plans. Some medication records are not up to date. Where self-medicating residents are non compliant with medication there is a lack of evidence of appropriate risk management having taken place. EVIDENCE: Our discussions with people who use the service evidenced that they are encouraged to choose their own clothes and hairstyle. The appearance of the people we spoke to reflected their personality. We spoke with one of the care workers on duty and they were able to describe to us the practical steps they take to ensure that privacy and dignity are respected during the provision of personal care. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 16 We looked at the personal files of two residents. One file contained a section within the personal plan that had been completed to evidence all the medical and healthcare appointments they had recently attended along with the outcome and any follow up. The plan also identified this resident’s reluctance and continued refusals to attend some healthcare appointments. However, for the second resident this section had been left blank in their individual plan. The provider subsequently told us that that this resident arranged their own healthcare appointments independently, and that they were working with them to develop a system whereby this could appropriately monitored. Previous inspections have evidenced that the home has developed a medication policy, and that this complies with National Minimum Standards. One resident was prescribed controlled drugs at the time of this inspection. We examined the controlled drugs register and found that this had been correctly completed. Another resident is self-administering oral medication. We looked at their personal file and noted that a risk assessment to address this activity had been completed. We looked at the available medication for two residents, and compared this to the Medication Administration Record (MAR). For one resident the available medication corresponded to that listed on their MAR sheet. The MAR sheet had also been appropriately completed. The second resident is identified as self-medicating, however the home continues to complete a MAR sheet and their medication is held in the homes medicines cabinet. We noted that one of this residents prescribed medications was not available, and that the MAR chart for this medicine had not been completed on the day of our inspection or the previous day. We asked care staff on duty about this, and were told that the prescribed medication had run out, and despite attempts by the home to encourage the resident to fill their repeat prescription they had been reluctant to do this. Sahara Lodge DS0000022847.V374492.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 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents told us that they are happy with the service provided. The home has a complaints procedure that is available in an easy read format. People that use the service are aware of how to make a complaint. The home has developed clear safeguarding policies and procedures. The staff we spoke to demonstrated a sound understanding of safeguarding issues. However, the home does not maintain a current complaints log in which to record the details of complaints along with the investigation undertaken and outcome. The home has not fully implemented its own safeguarding plan. EVIDENCE: The home has produced a Complaints policy and procedure that complies with National Minimum Standards. An easy read format of this policy was displayed within the home. We also noted that at residents meetings people who use the service were asked if they had complaints or concerns. We asked to see the homes complaints log. The Manager was unable to locate this, but did after some time locate an archived complaints log with entries dating from 2003 and 2004. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 18 We spoke to several residents, and they told us that they were aware of the complaints procedure, and knew how to make a complaint if there was anything they were unhappy with. The home has developed a safeguarding policy and procedure. This includes definitions of abuse, the types of abuse vulnerable adults may experience and possible indicators that abuse had occurred. The policy also clearly outlines the procedures for staff to follow should they have any safeguarding concerns, and this complies with local safeguarding protocols. The Commission for Social Care Inspection has been advised of one safeguarding incident since the last inspection. This was investigated by the local authority and not proven. The homes training records indicate that all care staff received safeguarding training in either September 2007 or August 2008. The member of care staff on duty at the time of this inspection was able to demonstrate a sound understanding of safeguarding issues and their responsibilities should they have any safeguarding concerns. The home produced its own safeguarding action plan in January 2008. We asked to look at this to review progress in its implementation. We noted that there were two action points that we could not evidence as being implemented, the first being a review of staffing levels. We asked the Manager about this, and they told us that a review had been carried out and we would be forwarded details. We did subsequently receive some additional information about staffing levels, but this related to another home owned by the Company. It was not evidenced that the home provided one takeaway and one restaurant meal per month at its expense to residents. We were subsequently told by the home that meals out are regularly provided to people who use the service, but that these are not claimed back through company expenses. Sahara Lodge DS0000022847.V374492.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 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides an environment that meets the needs of residents. People who use the service can personalise their rooms. However, the home must ensure that it is free from offensive odours. EVIDENCE: The home is situated in a large terraced house in a residential area with close proximity to local shops and amenities. A one bed roomed, self-contained flat in the basement of an adjacent house is registered as part of the care home. A number of repairs and maintenance issues were identified in the flat, and these are detailed in the requirements section of this report. The main house has a large lounge and dining area with a kitchen to the side. A laundry/utility room and a separate telephone room are also located off of Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 20 the lounge. To the rear of the property there is a large garden with lawns. A trampoline and goal posts have been erected in the garden. Residents each have their own bedrooms and these are located on the ground, first and second floors. The home has two bathrooms with WC’s - a walk in shower room on the ground floor and a bathtub on the second floor. Access to the upper floors is via a staircase. A small staff office is located on the ground floor and the Managers office is located on the first floor. Residents told us that they have their own room keys. Some residents showed us their rooms and we found that these had been personalised with pictures and mementos. The décor in some residents rooms was tired and marked and would benefit from refurbishment. During our tour of the premises we noted that there was a strong smell of urine on the first floor landing. Sahara Lodge DS0000022847.V374492.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): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs are supported to undertake NVQ level training. Some staff has completed specialist learning disability training. The homes recruitment procedures ensure the safety of people using the service. However, some care staffs are not evidenced as having received the minimum requirements of core training over the previous year, and staffs do not receive regular supervision. EVIDENCE: At the time of this inspection the home employed 12 carers. One resident who lives in a self contained flat attached to the residential care home receives 24 hour 1:1 care. Within the home two care workers are deployed during various busy periods during the day. At other times a single care worker is one duty. One waking night staff is also rostered on duty. Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 22 Four members of care staff have obtained NVQ level 2. An additional three care staff have obtained NVQ level 3, with another two care staff currently working towards this award. We looked at the homes staffing rota and found that this corresponded with the staffing situation we found in the home. We looked at the personnel files for the two care workers on duty at the time of this inspection. This evidenced that the home obtained an Enhanced Criminal Records Bureau (CRB) check and two satisfactory references prior to their commencing work. Since the last inspection five care staff have completed a recognised Learning Difficulty Qualification (LDQ). The Manager told us that this training also included person centred planning, first aid, food hygiene, health and safety and moving and transferring. Of the seven staff not involved in LDQ training, six were evidenced as having received two days core training in 2008 addressing safeguarding and challenging behaviour. One care worker was not evidenced as having received any core training since June 2007. We looked at the available supervision records for two care staff. This evidenced that each had received 2 supervision sessions in the previous year. Sahara Lodge DS0000022847.V374492.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, 39, 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 obtains the views of people who use the service, and appropriate insurance cover is in place. However, the home does not maintain a variety of records required by legislation, including fire and food hygiene related tests. EVIDENCE: At the time of this inspection a Manager had been appointed on a part time basis to manage the home, however they their post shortly after this inspection, and at the time of writing this report this post is vacant. We spoke to the Manager who told us that surveys for relatives and people who use the service had been carried out. We were also told that outcomes Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 24 from feedback surveys had been discussed at a Managers meeting, but that these had not been collated or published. We looked at the homes Quality Assurance folder and found completed surveys from people who use the service and from visitors. These indicated that people who use the service and their visitors are generally satisfied with the service provided. We examined a number of health and safety records the home is required to maintain by legislation. The homes records of weekly fire alarm call point tests indicated that in August, September, October and December a period of two weeks lapsed between tests being carried out or recorded. A fire evacuation drill was recorded as having been carried out in January 2008. It was not recorded how long the evacuation had taken, and it was not evidenced that a fire evacuation drill had been carried out since. We also looked at the homes record of fridge and freezer temperatures. This evidenced that these temperatures are checked twice daily and are maintained within acceptable parameters. We asked to see the record of fridge and freezer temperatures for the self contained flat that forms part of the homes registration, but the care worker on duty was unable to locate this. We looked at the homes record of water temperatures. These were evidenced as being carried out on a monthly basis with the recorded temperatures being at acceptable levels. We looked at the homes accident and incident book and found this to be in order. The home displays a current insurance certificate with appropriate cover. Sahara Lodge DS0000022847.V374492.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 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 3 2 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 3 2 X 2 X X 2 3 Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 26 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. Standard YA7 Regulation 12 Requirement Where the home places restrictions upon individual choice the reasons for this must be clearly documented. When such restrictions impact upon other residents the home must evidence that appropriate consultation has taken place. The home should develop more personalised community based activities for each resident based on their individual interests and abilities. This is a restated requirement. The previous target of the 30/06/08 was not met. 3. YA19 12 The home must maintain a record of all healthcare appointments attended along with their outcome and any follow up. All prescribed medication, including PRN medications must be available. 30/06/09 Timescale for action 30/09/09 2. YA12 16 30/09/09 4. YA20 13 30/03/09 Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 27 This is a restated requirement. The previous target of the 30/05/08 was not met. Where self-medicating residents become non-compliant with their prescribed medication the home must take appropriate, timely action. 5. YA22 4 & 22 The home must establish a complaints log, where the date, nature of the complaint, details of the complainant and the investigation undertaken, outcome and actions taken are all recorded. The home must implement its action plan to safeguard people who use the service. This is a restated requirement. The previous target of the 30/06/08 was not met. 7. YA24 13 & 23 The home should develop and implement an improvement and refurbishment plan for resident’s bedrooms. The home must ensure that shower hoses and showerhead fixings are updated and repaired. In the basement flat the following repairs and maintenance must be undertaken: (i) (ii) The broken front door handle must be replaced. Items stored in the kitchen area such as a wooden trim with Version 5.2 Page 28 30/06/09 6. YA23 13 30/06/09 30/09/09 Sahara Lodge DS0000022847.V374492.R01.S.doc (iii) (iv) nails in it must be removed. In the lounge an armchair with stained arms must be cleaned or replaced. In the lounge the damaged wall near the radiator must be made good. 30/05/09 30/09/09 8. 9. YA30 YA35 13 & 16 18 The home must be free from offensive odours. All staff must be evidenced as receiving at least five days paid training per year. The home must ensure that staffs receive regular supervision, a minimum of six each year. Outcomes from the homes annual feedback surveys from residents and other stakeholders must be collated and published. The home must carry out and record weekly fire alarm call point tests. The home must carry out regular fire evacuation drills and record these along with the time taken to complete the drill. The home must maintain a record of temperatures for all refrigerators and freezers, and this must be available for inspection. 10. YA36 12 & 18 30/09/09 11. YA39 24 30/09/09 12. YA42 12 & 37 30/05/09 Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 29 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 YA6 Good Practice Recommendations The home should ensure that life story work which includes significant events, relationships and educational and occupational achievements should be included in individual residents plans Sahara Lodge DS0000022847.V374492.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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.V374492.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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