Inspection on 16/05/08 for Shalom Home

This inspection was carried out on 16th May 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Shalom Home 09/04/09

Shalom Home 11/11/08

Shalom Home 12/10/07

Shalom Home 05/04/06

Shalom Home 22/11/05

Shalom Home 27/07/05

Shalom Home 04/01/05

Shalom Home 02/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Shalom Home Shalom Home 143 Caistor Park Road Stratford London E15 3PR Lead Inspector Lea Alexander Unannounced Inspection 16th May 2008 12:00 Shalom Home DS0000022875.V364299.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 Shalom Home DS0000022875.V364299.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. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Home Address Shalom Home 143 Caistor Park Road Stratford London E15 3PR 020 8471 9533 020 8471 9533 b.fadojutimi@btinternet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Bodi Fadojutimi Mr Bodi Fadojutimi Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 2007 Brief Description of the Service: Shalom Home is a small care provider for 3 adults with a history of mental illness. It was registered in July 1999 and the registered provider is also the registered manager. The premises are located in a terraced house on a residential street in Stratford. The accommodation comprises of a communal lounge and attached kitchen diner, bathroom with wc and garden. There is a staff office/sleep in room and two service user bedrooms located on the first floor, and a third service users bedroom located on the ground floor. There is a garden to the rear of the property and a large park nearby. The home has easy access to transport links and community facilities. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector over the course of three visits to the home on the 16th, 20th and 23rd May. The Inspector had visited the home on several occasions previously. This was an unannounced inspection focusing on key standards and the homes progress with requirements made at earlier inspections. During the course of the inspection we met with the Manager and spoke privately with two residents and two care workers. We also looked at a range of records relating to the running of the home including resident’s personal files and staff personnel files. The quality rating for this service is 0 stars. This means the people who use the service experience poor quality outcomes. What the service does well: What has improved since the last inspection? The home has been assessed as complying with a number of recommendations and requirements made at previous inspections. These include making an Occupational Therapy referral for one resident and scrapping a punitive bathing regime for another. Service users are supported to participate in the local community and take the lead in the choice of channels on the homes TV. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 6 The home maintains records of healthcare appointments and has improved its medication practises. The communal areas of the home have been repainted and the premises were free from offensive odours. Started, processed foods had been appropriately date labelled. The Manager is developing a staff training and development programme and two staff have enrolled for National Vocational Qualifications. The home has also collated and published the outcomes from its most recent quality assurance exercise. What they could do better: The home accommodates three male residents with mental heath needs. Residents have diverse ages and cultural backgrounds. The homes care staff and Manager is from similar African backgrounds. The home could better reflect the diversity of its residents and the local community. A number of requirements are restated from previous inspections. These include the homes plans not appropriately detailing or addressing residents health, personal or social needs. Advocacy services were not provided to one resident while they made a major financial decision, and potential risks are not appropriately assessed or managed. The home does not provide a variety of meals, and the menu is not reflective of resident’s preferences or cultural backgrounds. Staffs are not evidenced as receiving regular supervision or annual appraisal. In addition a number of new requirements were made as a result of this inspection. The home must ensure that plans are reviewed as the needs of residents change. The home must seek independent financial advice from appropriate sources for the resident who is liable to pay their own contributions. Where people who use the service are supported to make major life decisions detailed records must be maintained. All staff must be able to demonstrate a basic understanding of mental health issues and their impact upon people who use the service. The home must evidence that residents are engaged in the day-to-day running of the home. The Manager must carry out an investigation into a complaint about noise and feedback the outcome to the resident who has complained and to the Commission for Social Care Inspection. The home must ensure that each complaint it receives is recorded along with details of the investigation undertaken, outcome and action. The home must investigate the allegation made by one resident with regard to missing money in accordance with local safeguarding procedures. The home must ensure that robust procedures are in place to safeguard people who use the service, and that allegations are investigated in accordance with the homes safeguarding policy. Some minor repairs must be undertaken in the homes bathroom and the home must ensure that opened processed foods are used or disposed off in Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 7 accordance with the manufacturers guidance. We also recommend that the home should review its rota to include the dates and times of shifts and to indicate when the Manager will be on site. 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. Shalom Home DS0000022875.V364299.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 Shalom Home DS0000022875.V364299.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 provides clear information to potential residents. EVIDENCE: Previous inspections have evidenced that the home has produced a statement of purpose and service users guide that reflect the nature of the service provided. There have been no new admissions since the last inspection. Previous inspections have also evidenced that the home assesses potential residents prior to their moving in. Shalom Home DS0000022875.V364299.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 poor. This judgement has been made using available evidence including a visit to this service. Care plans are basic and do not address all areas of need. The home does not properly assess or manage identified risks. People who use the service have little input into how the service is run, and contact with advocacy services is not promoted. EVIDENCE: We case tracked two residents of differing abilities and needs. For each a range of individual plans had been developed by the home. Whilst some personal, social and health needs had been addressed by plans, these were not comprehensive, and some areas had no plans at all. For example one resident had no plans addressing social and family contacts. Discussion with the Manager and sampling of the daily log evidenced that this resident has frequent contact with their mother. For another resident the plan developed was not comprehensive. The plan was appeared to address mobility but Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 11 actually focused on a referral to the Occupational Therapist. The plan did not contain any information about the resident’s current abilities, difficulties, aids used, or the difference in their mobility within the home and in the community or their ability to use public transport. It was also not evidenced that the plans were updated as needs change. For example, we were told that one resident had been spending increasing time at a relatives house, and that this had been the subject of a meeting with the community team because of concerns that about how this was affecting their compliance with medication. This resident’s individual plan had not been updated to reflect this. We also saw that one resident has a plan to address their bathing needs. Discussion with the Manager established that there had been an improvement in this area, however the plan had again not been updated to reflect this. There was evidence that care workers regularly fill in a review sheet that the Manager then uses to update the plan. However, the quality of the information recorded for progress with some plans was extremely poor. For example when reviewing the “maintaining environment” plan for both residents “cleaned room” had been recorded. However there was no additional information, such as whether the care worker had completed the task or whether the resident had participated. There was also no information such as the nature of the cleaning tasks undertaken. Later on in the inspection we were given a second folder for each of the residents we case tracked. This also contained individual plans, and the Manager told us that the first folder contains the plans and review sheets that care workers refer to on a daily basis and that the plans in the second folder were for review by the Manager. We compared the contents of each folder and found that some of the plans did not appear in both folders. For example for one resident a plan headed “adaptability” did not appear in both files. People who use the service, care workers and the Manager told us that residents have their own bank accounts and manage their own finances. The Manager also told us that one resident has been identified as requiring support to manage their finances, but that they refuse to accept this. A previous inspection in October 2007 had recommended that the home, in conjunction with the community team, review the strategies in place to promote good personal hygiene for one resident. The Manager told us that this had happened and the previous system had been cancelled. The Manager also told us that some improvements in this area had meant that no further strategies had been developed. A previous inspection had also required the home to refer one resident for advocacy services regarding a major decision they needed to make regarding finances. However, it was not evidenced that this had occurred. We spoke to Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 12 the Manager about this and they told us that the decision had already been taken at the time of the earlier inspection. We queried why we had not been told this at the time of the earlier inspection, and also asked to see documentation evidencing the chain of events and timescales, but none was available. We talked to the resident, who could not recall the timescales involved. We looked at the minutes of residents meetings in the home. These were recorded as being held in January and March 2007, but it was not evidenced that a meeting had been held since. Discussion with two residents and two care workers did not evidence that there had been any other meetings to discuss the day-to-day running of the home. Sampling of the personal files for both the case tracked residents evidenced that a range of potential risks had been identified. However, the majority of the risk assessments sampled were found to be duplicates of the information written on the individual plan rather than a follow on assessment of an identified potential risk and an agreed management strategy. Shalom Home DS0000022875.V364299.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, 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 involved in daytime activities of their choice, and remain in contact with their families. However, the home does not provide meals that are varied, or that reflect the cultural needs or individual preferences of people who use the service. EVIDENCE: One person who uses the service spends much of their time away from the home; the Manager told us that the resident was thought to be staying with their mother. We were also told that this resident is able to access local community services such as shops and public transport independently. The Manager told us that this resident had declined day services and that their care was under regular review by the local community mental health team. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 14 The homes other two residents are older men both of whom participate in a weekly visit to local shops to complete the homes shopping, and a separate outing for lunch. One of the residents told us that they did not want to attend any other activities and that they were happy with how they spent their time. This resident has family that live locally, and they are supported to have contact with them. A third resident told us that they enjoy “being out and about”. This resident has some mobility needs and requires staff support to access the community. The resident told us that since the last inspection they had been given the opportunity to go out on a third afternoon each week, to a place of their choice such as a cinema or local restaurant. This resident has family living in Essex and they are supported to maintain phone contact and have occasional visits. Both residents that we spoke to told us that they were happy with the frequency and nature of activities that they were involved in. When we arrived we noticed that a 24-hour news channel was on the TV and that some residents were watching this. Two of the residents told us that they thought that since the last inspection they were taking more of a lead in choosing what TV channels and programmes were watched. People who use the service told us that they chose when to be alone or in company or when to join in an activity. One person who uses the service has special dietary requirements as a result of their religious beliefs. The resident told us that these are respected by the home and that acceptable foods were offered. Two people who use the service are diabetic. We spoke to one care worker about the types of foods that should be avoided in a diabetic diet, and they demonstrated a sound knowledge and understanding in this area. One resident has requested meals that are reflective of their cultural background. The Manager acknowledged that the home had not been able to provide these partially as the staff do not know how to prepare the required meals. We looked at the minutes of residents meetings, and noticed that whilst one had not been held recently in the past residents had complained about the meals provided. We spoke to two residents. One said they found the menu repetitive, and a second resident complained that too much chicken is served and that their requests for more lamb and beef are ignored. We also looked at the homes record of meals offered to residents and noted that there is little variation from week to week, and that during the course of the week the meals are repeated. Examples of this are a pasta and mincemeat dish that appears on the menu for the last consecutive five weeks, and twice a week in the last fortnight. A potato and chicken meal appears twice a week for the last two months. Chips and burgers were served twice in the week of the Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 15 inspection, as was soup. We noted that soup was also served three times in the week before the inspection. We looked at the foodstuffs available within the home. A supply of fresh fruits was on display and readily accessible to residents. An examination of the homes freezer suggested that little variation from the current menu was planned. Despite having been shopping for the home of the day it was inspected the homes fridge was poorly stocked and contained condiments, two yoghurts a single vegetable and a bag of salad. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be independent in their personal care, and to attend healthcare appointments. EVIDENCE: Discussion with two residents, the Manager and two care workers evidenced that residents require prompts and encouragement with personal care, but undertake these tasks without practical assistance. Since the last inspection one resident has been assessed by an Occupational Therapist and some aids and adaptations have been provided within the home as a result of this. Both of the personal files seen by us contained information on the healthcare appointments recently attended by residents, along with the outcome. We looked at the homes medication policy and noted that it had been updated to include information on the process for self-medication. We were told that none of the homes residents are currently self-medicating or using controlled Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 17 drugs. We sampled the available medication for two people who use the service and also looked at the corresponding Medication Administration Record (MAR). This evidenced that all the available medications were listed on the MAR and that the MAR sheets were in good order. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. The home maintains poor records relating to complaints. Where residents have made complaints there is little evidence of them being listened to, or the service improving. Whilst the staff and Manager have received safeguarding training this has not been put into practise, and safeguarding issues have not been addressed. EVIDENCE: Previous inspections have evidenced that the home has developed a complaints policy that complies with National Minimum Standards. Both of the residents we spoke to told us that they knew how to make a complaint. The meetings of resident’s minutes identified a number of complaints raised by residents, however examination of the homes complaints log did not evidence that these had been investigated or any action taken. We spoke with the residents who had made these complaints, but they could not recall being given any feedback or action being taken. We noted that residents repeated these same complaints to the Inspector during this inspection. One resident told us they were angry that a complaint about noise had not been dealt with, and that the problem was ongoing. When the complaints log was examined we found that the complaint had been logged in November 2007, however there was no record of any investigation undertaken, its Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 19 outcome or any action taken. We spoke to the Manager about this and asked them to carry out an investigation now and feedback to the resident. Residents also complained about the homes menu. The Manager told us that they had completed safeguarding training in 2005 or 2006, and that all staff had completed safeguarding training provided by the home in 2007. We were told that the training provided to staff was based around an interactive learning CD ROM. We asked how the home ensures that learning from safeguarding training is put into practise, and the Manager told us they asked for feedback at the end of the training and carried out informal observation of all care workers practise. The Manager told us that safeguarding is not looked at regularly in staff meetings or in one to one supervision. The Manager was aware of local multi disciplinary safeguarding protocols, and had contacts within the local authority safeguarding team. Copies of the local protocols were not however available on site. We spoke with two care workers who each demonstrated an awareness of the different types of abuse people vulnerable people might experience. One resident that we case tracked had a plan that identified “missing money” as an issue. This was first identified as an issue in late 2006 when the resident reported the money as missing from their room. The complaint investigation recorded at that time indicated that after discussion with staff it was concluded that the resident had been confused over the denomination of notes they had had. A plan addressing “missing money” was developed and remains on the personal file. Whilst sampling the review records for this plan we noticed that the resident made another allegation on the 4th May 2008 that monies were missing from their room. There was no record of this being logged as a complaint or a safeguarding issue, and no record of any investigation, outcome or action taken. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable environment with a range of shared and private spaces. Residents have their own bedroom. The home is generally well maintained. EVIDENCE: The home is situated in a Victorian terraced property in a quiet residential location close to public transport links and the nearby shopping centres at Stratford and Green Street. There is also easy access to the nearby West Ham Park. Entrance to the home is via a small porch that leads onto a hallway. An open plan lounge leads off this hallway and this has a range of comfortable seating, a TV and stereo. A door from the lounge leads to one resident’s bedroom. The lounge leads onto a kitchen with dining area. There are a range of fitted units along with the necessary appliances and a table with chairs. From the dining are there are patio doors to a paved garden area. From the Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 21 kitchen area there is a small hallway that leads into a bathroom. This has a WC, hand basin and tub with shower over. Access to the first floor is via a staircase and two residents bedrooms and a staff office can be found on this level. The home has completed a programme of refurbishment since the last inspection that includes the repainting of the lounge, stairway and bathroom. Some bedroom furniture has also been replaced. Some further minor repairs to the bathroom were identified as a result of this inspection, and these are detailed in the requirements section of this report. During the course of the inspection the home was found to be clean and free from offensive odours. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 22 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. Residents are generally happy with the care that they receive. Staffs are supported to undertake National Vocational Qualifications. However, staffs do not receive regular supervision or annual appraisal, and some staff lack basic mental health awareness. EVIDENCE: The Manager told us that no staff had left the home since the last inspection and that one staff member had joined the home after being redeployed from another part of the organisation. We were told that a total of five-support worker are currently employed within the home, and this corresponded with the information recorded on the current staffing rota. The Manager also told us that two staff has completed their National Vocational Qualifications (NVQ) at level 3, and that another two care workers had registered to commence their NVQ studies. We looked at the homes current staffing rota and found that it accurately reflected the care staff on duty at the time of our inspection. However, we Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 23 found that the rota recorded only the month and day and whether a day or nightshift was being worked. There were no dates, no times and no information on when the Manager might be available on site. We looked at the available personnel documentation for two care workers. The documentation for one staff member recently redeployed from within the organisation was initially limited to a training certificate and induction record. Later on in the inspection we were presented with a completed summary personnel information sheet that stated that an application had been completed and that two references, an Enhanced Criminal Records Bureau check and proofs of identity had been obtained. A second care worker had been in post since May 2007. A completed application form, two references and an enhanced Criminal Records Bureau check were available for us to see. The home had also obtained proofs of identity. The Manager told us that since the previous inspection a training and development programme had been developed. We were also told that all staff is expected to complete NVQ studies, and that all staff must complete core training. In addition we were told that infection control training and medication training were planned for later this year for all staff. Completed induction records were found in personnel documentation for both the care workers sampled. No training records were available for the staff member who had redeployed to the home. For the second care worker it was evidenced that they completed four days training since taking up post that included a generic two-day care assistant training and separate days for safeguarding and food hygiene training. We sampled personnel documentation for two care workers and also spoke with the Manager and two members of staff. However, we were unable to evidence that annual staff appraisal takes place. For the recently redeployed member of staff there were no records of any supervision having taken place. For the longer serving member of staff supervision records for December 2007 and March 2008 were located. The Manager and care worker told us that supervision also occurred informally during the shift, however we noted that according to the shift rota this carer works a night shift at the weekends and that the Managers hours were not included in the rota. One of the care workers sampled by us had no formal training or experience as a carer prior to taking up their employment with the home. Our discussion with this care worker evidenced previous experience as a carer to a family member. However, during discussions we noted that their knowledge and understanding of mental health issues and their impact upon people who Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 24 experience mental illness was very limited. The worker was unable to describe the type of symptoms that residents within the home experience, or tell us how these might impact upon resident’s daily lives. The care worker was also not able to tell us what things they might start to notice if a resident’s mental health was deteriorating. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 25 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager is suitably qualified and experienced. The home completed its self-assessment form and submitted this to the Commission. The Manager demonstrated an awareness of person centred planning and safeguarding, but there was little evidence of this being put into practise. EVIDENCE: The Manager told us that they had completed their NVQ level studies and were waiting for their certificate. Since the last inspection the home has collated and published the outcomes of its most recent quality assurance exercise. In addition to people who use the Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 26 service, professionals and staff also completed surveys. Responses to each area of the survey ranged between neutral and good. We examined a number of health and safety records maintained by the home. These evidenced that weekly fire alarm call point tests are carried out, and that the system is maintained in good order. The homes record of fridge and freezer temperatures also evidenced that the home monitors these on a daily basis and temperatures are maintained within acceptable limits. The home was also evidenced as regularly monitoring water temperatures and maintaining these within acceptable limits. We also looked at the homes accident and incident logs and found that they were appropriately maintained. A current Portable Appliance Testing certificate was also seen. We looked at the contents of the homes fridge and found that started, processed food items had been date labelled, however one food product had been retained past the manufacturers specified period for use once opened. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 27 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 1 23 1 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 1 1 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 28 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 YA6 Regulation 14 & 15 Requirement The home must ensure that individual plans appropriately detail the health, social and personal needs of people who use the service. This is a restated requirement. The previous target of 30/12/07 was not met. The home must ensure that plans are reviewed as needs change. The home must ensure that appropriate advocacy services are provided to people who use the service. The home must seek independent financial advice from appropriate sources for the resident who is liable to pay their own contributions Where people who use the service are supported to make major life decisions detailed records must be maintained. The home must evidence that residents are engaged in the DS0000022875.V364299.R01.S.doc Timescale for action 30/11/08 2. YA7 16 & 20 30/11/08 3. YA8 24 30/11/08 Shalom Home Version 5.2 Page 29 day-to-day running of the home. 4. YA9 13 The home must ensure that identified risks are appropriately assessed and subject to a management strategy. The home must ensure that a range of suitable menus that meet the dietary and cultural needs of residents are provided, and that these reflect their individual preferences. This is a restated requirement. The previous target of the 30/12/07 was not met. A variety of nutritious meals must be provided. The Manager must carry out an investigation into a complaint about noise and feedback the outcome to the resident who has complained and to the Commission for Social Care Inspection. The home must ensure that each complaint it receives is recorded along with details of the investigation undertaken, outcome and action. The home must ensure that robust procedures are in place to safeguard people who use the service, and that allegations are investigated in accordance with the homes safeguarding policy. The home must investigate the allegation made by one resident with regard to missing money in accordance with local safeguarding procedures. The following repairs and maintenance must be carried out in the bathroom: (i) Shalom Home 30/11/08 5. YA17 Sch 3&4 30/11/08 6. YA22 22 30/11/08 7. YA23 13 30/11/08 8. YA24 13 & 23 30/11/08 A plug must be fitted Version 5.2 Page 30 DS0000022875.V364299.R01.S.doc 9. YA35 18 10. YA36 12 & 18 to the bath (ii) The broken bath panel must be replaced (iii) The toilet seat must be secured. The home must ensure that all staffs demonstrate a basic understanding of mental health issues. Staff must receive an annual appraisal with their Manager to review their performance. This is a restated requirement. Previous targets of the 28/02/06, 31/07/06 and 30/03/08 were not met. Staff must receive a minimum of six supervision sessions per year. 30/11/08 30/11/08 11. YA42 13 This is a restated requirement. The previous targets of 31/07/06 and 30/03/08 were not met. The home must ensure that 30/11/08 opened processed foods are used and disposed off in accordance with the manufacturers guidance. 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 YA33 Good Practice Recommendations The home should review its rota to include the dates and times of shifts and to indicate when the Manager will be on site. Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Contact Team 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 Shalom Home DS0000022875.V364299.R01.S.doc Version 5.2 Page 32 - 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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