Inspection on 12/09/05 for Sharon House

This inspection was carried out on 12th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Sharon House 08/11/07

Sharon House 05/02/07

Sharon House 16/10/06

Sharon House 21/03/06

Sharon House 14/12/04

Sharon House 21/06/04

Similar services:

Cowden Road, 52 - 54

Norbury Crescent (30)

Chatsworth Care - Tudor Lodge

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

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

CARE HOME ADULTS 18-65 SHARON HOUSE 24 Sharon Road Enfield Middlesex EN3 5DQ Lead Inspector Jackie Izzard Unannounced 12 September 2005 @ 9:30 am 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 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 Stationary 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. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sharon House Address 24 Sharon Road, Enfield, Middlesex, EN3 5DQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8804 5739 Mr Chandra Jootun Mr Chandra Jootun PC Care Home 5 Category(ies) of LD registration, with number of places SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two specified service users who are over 65 years of age may remain accommodated in the home. The home must advise the registering authority at such times as either of the specified service users vacates the home. Date of last inspection Brief Description of the Service: Sharon House is situated on a quiet residential road in Enfield, a short walk from Brimsdown train station. Residents can reach Enfield Town by bus or train. The home is registered for five adults aged between 18 and 65 years who have a learning disability. There is also a condition allowing the home to continue to care for two people who are now over the age of sixtyfive. The current residents are aged between 61 and 80 years. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 12 September 2005. The home did not know that the inspector was coming. There were three staff on duty during the morning and the inspector was able to meet all the five residents. There were four men and one woman at the home. The inspector also looked around the building, checked some of the home’s records and checked up on whether the owner/manager had completed all the things he was asked to do at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: At the last inspection of the home, seven requirements were made. These were improvements that the owner/manager needed to complete so that the home met the national minimum standards for a care home. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 6 Three of these requirements had not been completed satisfactorily and are repeated at the back of this report. A further two requirements are made in this report. The owner/manager of the home is asked to do the following by 31 October 2005; carry out a risk assessment for one resident (to try and ensure the resident’s safety when taking medicines when s/he is away from the home), ensure the home has a clear written procedure for staff to follow if a resident is at risk of abuse and to ensure the bottom part of the garden is safe. The two new requirements in this report are to send the inspector written information to show that the residents are protected from any risk of fire in the home (record of fire drills and a fire risk assessment which should list any risks of fire and what action is taken to reduce the risks). 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. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 5 Residents have an individual contract with the home which sets out the terms and conditions of their placement there. EVIDENCE: A sample of two files were checked for evidence of a contract. These were in place and met the required standard. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 Residents’ care needs are clearly recorded in a care plan and goals are set with each resident. The standard of these plans is satisfactory. Residents are supported to take risks and the risks are recorded and reviewed regularly. A requirement to assess a risk to one resident when he is not in the care of the home has not been met so is repeated. EVIDENCE: Three care plans were inspected on this occasion. These addressed the global needs of the resident and contained goals and how these were to be achieved. The plans are reviewed annually with their care manager. Each resident had risk assessments relating to their individual needs. These were reviewed on a six monthly basis and changed if necessary. One resident said that he goes on holidays and trips with a relative. A requirement was made at the last inspection that the owner/manager undertakes a risk assessment relating to the medication arrangements when this resident stays away from the home with a relative. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 10 There was no written risk assessment in this resident’s file for this issue. This requirement was discussed with the owner/manager after the inspection and he agreed to write a risk assessment . SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 17 Residents at this home have weekly activity plans and have opportunities to go out in the community. They are supported by staff to maintain relationships with family and friends and enjoy an annual holiday together. The diet offered is adequate to meet their needs. EVIDENCE: At the time of the inspection, none of the residents were attending any adult education but the inspector was told that one person is on a waiting list for a cookery course that s/he has done before. The level and type of activity in the home reflects the age of residents. Each resident has a weekly activity plan. The plans include activities such as household chores and baking, art and going for walks. Two residents said that they had been to the cinema with staff and two go to the local shop on their own. Staff accompany residents to shopping trips and out to places of interest. One resident said that he uses the local library. One person attends a daycentre twice a week. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 12 During the inspection, residents were watching television or reading. One was asked by staff to do an art activity, which was colouring in a children’s colouring book. The inspector was not able to communicate with this person to see whether s/he liked this activity. One person helped the staff with cleaning and seemed to enjoy this. Another resident said that his/her main interests were the theatre, museums and dogs. The resident said he would ask staff if he could be escorted to the theatre and a museum. A staff member told the inspector that she was hoping to provide this resident with the opportunity to spend time with dogs. All the residents went on holiday to Herne Bay this summer which is very positive. Staff encourage residents to keep in touch with friends and family if they have any. One resident said that two friends visit him/her every week and are made welcome by staff. Another resident is visited by a cousin every week. A third resident visits an aunt regularly. The menu for the week of the inspection was seen. The menu for the day of the inspection was cereal and toast for breakfast, meat pie, boiled potatoes and vegetables for lunch and chicken sandwiches, salad and fruit for tea. It was noted that residents have sandwiches for tea most days. A resident said that they do not make their own breakfasts as everybody eats together. Breakfast was served at 10am on the day of the inspection. The inspector did not ask residents if they were happy with this arrangement. One resident is diabetic and staff said that they ensure this person eats a healthy diet and has plenty of exercise. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 The home meets residents’ health needs and keeps good records of their health appointments. EVIDENCE: The majority of residents need some support with personal care but all are able to complete some personal care for themselves. One resident said that staff help him/her with having a shower and that staff are helpful. The manager carries out a quality audit of the residents’ individual files to ensure healthcare needs are being addressed. The audit shows the last appointment with the doctor, dentist, optician, chiropodist and any other healthcare professional. The audit also gives the date of the residents’ last flu vaccination and a record of their weight. This is an effective way of monitoring that a home is meeting people’s healthcare needs and the manager is commended for this good practice. Monthly checks on residents’ weight are recorded to ensure that their weight is not causing concern. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The home has a satisfactory complaints procedure but has received no complaints about the service. Residents are not fully protected from the risk of abuse as there was no evidence that staff know what to do if they have a suspicion or allegation of abuse. EVIDENCE: The home has a complaints procedure which meets minimum standards. There have been no complaints about the home. A recommendation made in the last inspection report that the owner/manager should add columns into the complaints book to record the action taken and outcome of any complaint has not been acted on. It is expected that this will be undertaken if the home receives a complaint. A requirement was made at the last inspection that the home have a clear adult protection procedure for staff to follow . The staff on duty was not aware of this procedure. The requirement is therefore restated as it is essential that staff have clear guidance on what to do if they have any suspicion or allegation of abuse to deal with. After the inspection, the owner/manager and the inspector spoke on the telephone. He assured the inspector that there was a procedure in the home and agreed to ensure all staff were familiar with the procedure. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 The home is comfortable, clean and safe for the people who live there. The rear section of the garden needs to be assessed for safety. EVIDENCE: The inspector looked at all rooms and the gardens. The house was clean throughout and staff were seen to be engaged in cleaning duties. The décor and furniture were of a satisfactory standard. There is an area at the bottom of the back garden that the previous CSCI inspector required the registered person to undertake a risk assessment on to identify and act on any health and safety issues. This risk assessment was not available for inspection and so the requirement is repeated in the back of this report for the third time. There is no specialist equipment used at present other than a wheelchair for long distances outside the home. This may change in the near future due to the age of all the residents. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 The residents of this home are looked after by a stable staff team who are all working towards a relevant qualification in caring for adults. EVIDENCE: The inspector was unable to gain access to staff records to look at records of training. This was because the manager was not on duty and the files were kept securely locked for confidentiality reasons. A member of staff told the inspector that one staff member is undertaking NVQ level 3 at the moment and all the other staff are undertaking NVQ 2. This is very positive. Records of staff training will be requested at the next inspection of the home. There is a stable staff team with a low turnover of staff. There is a minimum of two staff on duty between 8an and 8pm and one at night. The inspector was informed that resident s have low needs at night time. Although staff files could not be inspected on this occasion, the inspector followed up a requirement from the previous inspection that a CRB disclosure was obtained for a specified staff member by 20/12/04. An immediate requirement was issued to convey the urgency of completing this requirement. It was therefore of concern that the owner/manager told the inspector that this staff member still did not have a CRB disclosure nine months after this SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 17 requirement was made. He said that an application was made in May to the Criminal Records Bureau and that the result was delayed. Although this was the case and the owner/manager sent a copy of the CRB to the inspector as soon as he received it shortly after this inspection, it was of concern that an application had not been made as soon as the immediate requirement was issued. The owner/manager said that he is fully aware of the requirement to undertake a new CRB disclosure for any future staff or volunteers before they start work at the home. All staff at the home have a satisfactory CRB disclosure now. A recommendation from the last inspection, that staff supervision content is further developed is repeated in this report as the inspector could not access these records. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health and safety of residents appears to be generally well promoted, but further evidence of good practice in fire safety (fire risk assessment and records of fire drills in 2005) is required in order to ensure residents are fully protected from risk of fire. EVIDENCE: The inspector requested a selection of health and safety records to see if the health and safety of residents was being properly protected. The fire alarm system had been serviced in August 2005 and the fire extinguishers in June. The gas appliances had been serviced in November 2004 so were still up to date. The home was visited by Enfield Council Environmental Health Department in April 2004 and an informal notice was served . Staff told the inspector that the action identified in the report had been completed. Staff check the fire alarm system is working every week and there are weekly health and safety checks of the home(which they call risk assessments). SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 19 There was no record of any fire drills in 2005 in the fire book. The owner/manager told the inspector on the telephone that this record was in the home but staff had been unable to find it on the day of the inspection. He agreed to send a copy to the CSCI. A resident told the inspector that the lounge door, which is a fire door, is usually kept open and s/he was feeling upset that the door had been closed that day. All fire doors were closed when the inspector was in the home and the inspector did not see any fire hazards during an inspection of the house. The inspector requested to look at the home’s fire risk assessment but staff on duty did not know where it was. It is therefore a requirement that the owner/manager sends a copy to the CSCI as evidence that there is an up to date fire risk assessment for the home. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SHARON HOUSE Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9, 20 Regulation 13(4)(b) Requirement The registered person must ensure a risk assessment is undertaken relating to medication arrangements concerning a specified resident when staying with a relative. This requirement is restated (previous timescle of 31/1/05 not met). The registered person must ensure that Sharon House has an adult protection proedure which sets out clearly the steps to be taken by staff and management in relation to adult protection issues. This requirement is restated(previous timescale of 31/1/05 not met). The registed person must ensure that a risk assessment is made on the area at the bottom of the garden so that any health and safety issues can be identified and dealt with. This requirement is restated (previous timescales of 31/8/04 and 22/12/04 not met). THe registered person must send a copy of this risk assessment to the CSCI. The registered person must send the CSCI a copy of the record of Timescale for action 31 October 2005 2. 23 13(6) 31 October 2005 3. 24 13(4)(a) 31 October 2005 4. 42 23(4)(e) 31 October 2005 Page 22 SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 5. 42 23(4)(a) fire drills for the home, ensuring that these are carried out at least four times a year. The registered person must send a copy of the homes fire risk assessment to the CSCI and ensure that a copy is available in the home for staff to refer to. 31 October 2005 6. 7. 8. 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 36 Good Practice Recommendations The registered person should ensure that staff supervision sessions are developed further so that they encompass all the areas highlighted in national minimum stadnrd 36.4. This recommendation is restated as it was not checked at this inspection. SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection North London Area Office Solar House, 1st Floor 282 Chase Road London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI SHARON HOUSE G59 S10653 Sharon House V222865 12.09.05 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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