Inspection on 08/11/07 for Sharon House

This inspection was carried out on 8th November 2007.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sharon House 05/02/07

Sharon House 16/10/06

Sharon House 21/03/06

Sharon House 12/09/05

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 Caroline Mitchell Key Unannounced Inspection 8th November 2007 10:30 Sharon House DS0000010653.V350148.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 Sharon House DS0000010653.V350148.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. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sharon House Address 24 Sharon Road Enfield Middlesex EN3 5DQ 020 8804 5739 F/P 020 8804 5739 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 Chandra Jootun Mr Chandra Jootun Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 specified residents 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 residents vacates the home. 5th February 2007 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 5 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 2 people who are now over the age of 65. The current residents are aged between 62 and 80 years. The home is owned and managed by Mr Chandra Jootun. The cost of placements was reported by the registered manager to be £570680 per week. Following Inspecting for Better Lives, the provider must make information available about the service, including inspection reports, to residents and other stakeholders. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis and was conducted over 2 days, taking around 10 hours to complete. The inspector met the registered manager on the 2nd day of the inspection. Over the 2 visits the inspector met 3 members of the staff team and was able to meet all 4 of the residents, and speak to 2 residents at length and in private. The inspector also met 2 friends of a resident, who are regular visitors. The inspector was shown around the home by a resident and reviewed a number of written records kept in the home including the written records for 3 residents, all staff, along with records regarding health and safety, complaints, accidents, medication, residents’ activities and the food served in the home. What the service does well: What has improved since the last inspection? What they could do better: The main area for improvement identified at this inspection is the risk assessments for residents. These need to be much more comprehensive, and in order to achieve this it is necessary for at least 1 member of the staff team to undertake training in risk assessment. Residents also need to have health care plans. There is also a need to ensure that the written material concerning residents to be presented in a way that is more accessible and person centred in order to support them to be as involved in the decision making process as they can and as independent as possible. Some staff need updated training in Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 6 food hygiene and it would be beneficial if staff were to receive training in diabetes. Each staff member’s personnel file needs to include an up to date photograph. The registered person also needs to take advice from the appropriate professionals regarding providing weekend medication to resident without the secondary dispensing of medication, and regarding safer ways of keeping internal doors open. 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. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home have been provided with a statement of terms and conditions/contract. It gives basic information on what people can expect to receive and the charge for the service, and sets out terms and conditions of occupancy. These can be improved by ensuring that they are written in a format that is more accessible to residents. EVIDENCE: No residents have moved into the home for at least 4 years and the standards about the admission process were not inspected. At the previous inspection the registered person was required to ensure that fee section on residents individual contracts are completed. At this inspection the inspector was able to confirm that this issue had been addressed. The inspector reviewed the written records of 2 residents and found that both included written contract that were completed to include the charge for the service, and signed by the residents and their representatives. These were reasonably clearly set out, but there is room for improvement in that they could be made more accessible to residents by the use of a larger typeface and simpler, more person centred language. A recommendation is made in respect of this. The inspector noted that correction fluid had been used on 1 contract. The registered manager explained that this had not affected or altered the detail of Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 9 the contract. The inspector offered a reminder that the use o correction fluid on documents of this nature may affect their validity. Sharon House DS0000010653.V350148.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, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is some evidence that residents are involved in some decision making about the home, such as day to day living and social activities. Each individual has a care plan. These can be improved by ensuring that they are written in a format that is more accessible to residents. The plan includes information necessary to deliver the resident’s care but is not very person centred. Care plans are reviewed and updated as required by the NMS. The homes procedures describe the arrangements for providing Key Workers to support individual residents. Risk assessments are completed but these are basic and mainly focus on keeping people who use the service safe. Where limitations are in place, there is evidence that decisions are agreed with the individual and discussed as part of a multi-disciplinary approach. Documentation is provided but often not in formats understandable to individuals. EVIDENCE: The inspector reviewed the written records of 2 residents in some depth and looked at written information regarding specific areas of 1 resident’s needs. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 11 Each person’s files included care plans, and evidence that these had been reviewed regularly. They were of a good standard and addressed all relevant areas of people’s lives. However, there room for improvement in that they could be made more accessible to residents. A recommendation is made in respect of this. At the previous inspection requirements were made regarding ensuring that changes pertaining to residents needs were communicated to staff and documented on the person’s file. At this inspection the inspector was able to confirm that this issue had been addressed. The files seen were up to date and the inspector noted minutes of staff meetings reflected that each person’s needs, progress and wellbeing were discussed as a standing item. At the previous inspection the registered person was required to ensure that the specific resident, whose risk assessment was found to be very brief, is amended to ensure that the specific information pertaining to their overall care and support needs is clearly documented. The inspector noted that all of the staff have worked in the home for several years so they have been able to get to know the residents’ strengths and needs very well. A lot of the practice around working positively with residents with the risks in their lives has evolved over time and known to all staff, thus the risk assessments are very brief. They do not properly describe the risks as relevant to each person, or provide clear guidance regarding the necessary interventions to reduce them. Although 1 person’s history states that there is a risk of verbal and physical aggression, and others’ records reflect that they have diabetes, these issues have not been risk assessed. The registered manager acknowledged that there is a need to develop the risk assessments further, rather than relying on staff’s knowledge and word of mouth and requirements are made in relation to this. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have the opportunity to develop and maintain important personal and family relationships. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. People are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. Where appropriate education and occupation opportunities are encouraged, supported and promoted. They can access and enjoy the opportunities available in their local community, e.g. using public transport, library services, the local pub, and local leisure facilities. Where appropriate, are involved in the domestic routines of the home, they take responsibility for their own room, menu planning and cooking meals, making sure that they are able to enjoy the food they prefer and like. The menu is varied with a number of choices. The meals are balanced and nutritional and cater for people’s varying dietary needs. EVIDENCE: Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 13 The inspector reviewed the written records for 3 residents and noted that the activities that they had been involved in included baking, games, arts and crafts, life skills, puzzles, gardening, walks, cinema, trips to Enfield town, being involved in domestic activities such as making lunch. 1 person goes to a relative for overnight stays on a regular basis. People attend various colleges and centre during the daytime. On day 1 of the inspection 2 residents went to the library accompanied by a staff member and on day 2, a staff member accompanied 3 people to get fish and chips for lunch, and they went out to the cinema in the afternoon. At the previous inspection the registered person was required to consult with the specific resident or their representative on their behalf, regarding their overall cultural needs. At this inspection the inspector was able to confirm that this issue had been addressed. There is plenty of evidence that residents are encouraged to maintain contact with relatives and friends. The inspector noted that birthday parties had been arranged for people in the summer and there was evidence of lots of visitors to the home noted in the visitors’ book. The inspector met 2 friends of 1 resident, who visit about once a week. 1 resident told the inspector that he goes and stays with a relative quite often and that they sometimes go to on holiday together or to the seaside for day trips. 2 of the people living in the home are brothers and 1 told the inspector that they were pleased that they have been able to stay together as a family. 1 person is a smoker and smokes in the garden, saying that they are happy to do so. Some restrictions are placed upon this person’s freedom in relation to this, and the inspector noted that several references are made in the person’s records, risk assessment, care plan, and reviews, including written agreement from their psychiatrist. The inspector saw lots of fresh fruit and vegetables in the fridge. A staff member told the inspector that the registered manager does the main food shop, but that residents get plenty of opportunity to go shopping, for their own personal items and like to have a treat and lunch whilst out. The main meal is at lunchtime and the inspector was invited to share lunch on day 1. The meal was well presented and very appetising and matched the menu, which was displayed in the kitchen. During lunch, the inspector sat and talked with 1 staff member and 1 resident. The menu provides plenty of opportunity for choice. A staff member said people are consulted as the menu is planned on a weekly basis and that they check again on the day, if people want an alternative. The inspector noted that some staff’s training in food hygiene was provided more than 3 years ago, and a requirement is made for them to receive updated food hygiene training. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to health care services in the local community. People attend local GPs, dentists, opticians and other community services. Health needs are monitored and appropriate action and intervention taken. The care plan includes some reference to health care treatment and intervention, and a record of general health care information is kept. However, there is a need for a health care plan to be developed for each person. Staff encourage people to be independent and to take responsibility for their own personal hygiene. There are people living in the home who have diabetes and there is a need to provide staff with training regarding this. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. The home understands the need to comply with the administration, safekeeping and disposal of medication. The medication system does not follow good practice guidelines in respect of secondary dispensing, and a requirement is made in respect of this. EVIDENCE: The inspector noted that care plans reflect people’s personal care needs and that they are quite independent and generally require prompting. The Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 15 inspector saw information in staff meeting minutes reminding staff to prompt people to wear clothing appropriate to the weather, along with reference to further discussion regarding people’s personal care needs. At the previous inspection, 1 resident had recently died and it was recommended that the registered person seek advice and support for residents and staff with regards to bereavement & loss. At this inspection the inspector was able to confirm that these issues had been addressed and people were talking openly about how they missed the person. The inspector reviewed the written records for 2 people regarding their health care needs and noted that there is evidence of good monitoring of people’s health care issues and appointments, showing that these are taken seriously and people are supported to gain access to the appropriate health care service. However, not all residents have health care plans and a requirement is made in respect of this. Of the 2 files seen by the inspector, 1 resident had diabetes. The inspector noted that there was plenty of evidence that they were receiving good support from their dietician and GP, and were visiting the diabetic clinic regularly. The inspector was told that 2 residents were diabetic and spoke to 1 staff member who told the inspector that they were also diabetic, and were quite knowledgeable about the condition. However, it was noted that the staff team generally have not received formal training in this area and a requirement is made in respect of this. The inspector noted that medication is stored appropriately in the home and reviewed the records of administration, and of all medication coming into and leaving the home. The records were up to date, and there were no gaps. A record was also kept of the temperature at which the medication was stored. The inspector saw the record of the most recent monitoring visit, undertaken by the pharmacist in May 2007. The report indicated that the overall arrangements regarding the handling of medication were satisfactory, only a few minor recommendations were made, and the registered manager had addressed these. The inspector noted that when 1 resident went on weekend leave, the staff were dispensing medication into a separate dossette box for the resident to take with them. This task was being undertaken by 1 staff member, who was signing for this. A requirement is made for the registered manager to seek alternatives to secondary dispensing of medication by staff in these circumstances. At the time of the inspection the arrangement was changed to ensure that in the future a second staff member is present at the time the medication is dispensed as an extra safeguard. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows residents to express their views, and concerns in a safe and understanding environment. Residents and others involved with the service say that they are happy with the service provision, feel safe and well supported by staff in the home. The complaints procedure is supplied to everyone living at the home and is displayed in the home. Residents understand how to make a complaint and are clear about what will happen if a complaint is made. The home keeps a record of complaints. Training of staff in the area of protection is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. EVIDENCE: The inspector noted that reference was made in review notes, to some concerns raised by 1 resident’s relative. The registered manager explained that these concerns were not made to the home, but to the social worker, and were dealt with in the review. There have been no complaints received by the home since the previous inspection. The inspector noted that relations do at times become strained between the home and this particular relative. However, there is evidence that the issues are properly discussed with the social and health care professionals involved with the resident. It was evident that this relationship is important to the resident and that their opportunities to maintain it has not been affected. The inspector spoke to 2 residents in private and at length and neither had any complaints about the home. Both were clear that they felt confident to speak to the staff about how they are feeling. The visitors to the home, who Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 17 spoke to the inspector also gave positive feedback and had no concerns to raise. There had been an incident earlier that day where 1 resident had shouted and been aggressive towards a staff member, and 1 resident did say that this behaviour had shaken him. However, he was quite understanding of the other person’s distress and said that generally he felt safe and settled in the home. The inspector discussed this incident with the registered manager was clear that the home had acted appropriately in response to this issue, and had taken steps to inform and seek support from the professionals involved with the resident concerned, in a timely fashion, in order to discuss further strategies to minimise the likelihood of the recurrence of this kind of incident. Records reflect that all staff have had training in safeguarding people from abuse and in managing challenging behaviour. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 18 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, 26, 27, 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 physical environment that is appropriate to the specific needs of the people who live there. People are encouraged to personalise their bedrooms. The shared areas provide a choice of communal space. The bathrooms and toilets are in sufficient numbers and of good quality. The home is well lit, clean and tidy and smells fresh. EVIDENCE: 1 of the people living in the home showed the inspector around. During the tour of the home the inspector noted that the dining kitchen reasonably well equipped, and that this included a dishwasher. There was also evidence that staff and residents were getting involved in the council’s recycling scheme. There is a nice sized, private garden. Staff and residents told the inspector that they have barbeques in the warmer months. The lounge is reasonably spacious, and there are leather sofas and chairs, a television and DVD player. There is also a table in lounge, and it was evident that this is where residents sit to do arts and craft activities, and games and puzzles. The inspector noted, that the carpet was beginning to look worn. A staff member said that Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 19 the registered manager is looking into replacing it with laminate flooring and the inspector saw evidence that he is looking into providing new floor covering in lounge. In discussion with staff and residents it was evident that they had been thinking about re-decorating the lounge to make it more homely. There is a well-equipped laundry room on 1st floor with a washing machine, a dryer, and wash hand basin. Each person has their own bedroom. There was evidence that they had been encouraged to personalise their rooms, and they reflected people’s interests. There is a shower room with a toilet downstairs, bathroom with a toilet upstairs. 1 person said, “I like my room”, and another said they were very happy and comfortable, with their things around them. The house was reasonably clean and no unpleasant smells were detected. . Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 20 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, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare of people living in the home. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The manager is aware that there are some gaps in the training programme and plans to deal with this. Staff are clear regarding their role and what is expected of them. People living in the home report that they have confidence in the staff working with them. EVIDENCE: The inspector was provided with a copy of the planned rota. At the time of the 2 inspection visits the care staff on duty matched that which was planned on the rota. The rota indicated that there are usually 2 care staff on duty throughout the day, and 1 at night. All of the staff have worked in the home for several years and have formed a good team. They have been able to form very solid relationships with the residents and get to know their strengths and needs very well. The residents spoken to were very appreciative of this. Although there has been no new staff for 4 years the registered manager provided evidence that the home is equipped with the skills for care induction material in readiness for any new staff recruited. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 21 On day 1 of the inspection the registered manager was noted on the rota as working from 10 am to 4 pm, but did not come to the home. He did attend on day 2 and the inspector was able to talk to discuss several aspects of the running of the home with him. The inspector reviewed the personnel file for all staff and found that found that they did not include a recent photograph for each person. A requirement is made in respect f this. At the previous inspection the registered person was required to supply written evidence that 2 outstanding CRB disclosures had been applied for. At this inspection the inspector was able to confirm that this issue had been addressed. However, the inspector noted that 2 staff last had CRB checks in 2003, at a time before POVA check were included and a recommendation is made in respect of this. At the previous inspection the registered person was required to ensure the staff have all been trained on how to positively support the residents who have challenging behaviours. At this inspection the inspector found that all staff have been provided with training in this area. In addition 1 staff member told the inspector that they were arranging further updated training regarding health and safety and infection control. At the previous inspection the registered person was required to ensure that all the staff have regular supervision, the content of which meets standard 36 of the national minimum standards for care homes for adults. At this inspection the inspector saw evidence that all staff had supervision in 10/07. The registered manager said that he disposes of the notes, regularly. A requirement is made that evidence of regular supervision be maintained on people’s files. The registered person was also previously required to ensure that all the staff have an annual appraisal and this met. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 22 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 service is planned to be user focused, to take account of equality and diversity issues, and generally works in partnership with people’s families and professionals. The manager is improving and developing systems that ensure that resident’s feedback is used in monitoring the quality of the service. More work is needed in this area. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. There is a need for improvement in fire safety regarding propping internal doors open. EVIDENCE: The registered person is also the registered manager and runs the home on a day-to-day basis. The inspector noted that staff meetings take place regularly and provide an opportunity for good practice and various aspects of the running of the home to be discussed. At the previous inspection the registered person was required to undertake a quality assurance exercise Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 23 seeking the views of the residents, their relatives and other care professionals and once the views have been received this must be collated into an action plan. The inspector noted that the residents had completed questionnaires regarding their satisfaction with the service, and that some had been able to do this themselves, whilst staff had completed the form for others. A staff member told the inspector that there is a regular visitor, who is a relative of the resident who recently died, but has good relationships with the other residents and likes to visit them regularly, and that this person may be willing to act as advocate in order to help people complete their questionnaires in the future. The inspector noted that the questionnaire used for relatives and other professionals is more simply presented and more accessible and could be adapted for residents. Recommendations are made regarding the format of the residents’ questionnaire and the support that they receive in order to complete it. The information provided to the Commission by the registered manager in the form of the annual quality assurance assessment indicated that all of the necessary equipment checks had been undertaken and the inspector saw evidence that the PAT (portable electrical appliance testing), emergency lights, and fire equipment tests were up to date. At the previous inspection the registered person was required to amend the fire safety risk assessment to include a section relating to an emergency plan procedure. At this inspection the inspector was able to confirm that this issue had been addressed. The inspector noted that it is common practice for the doors to the office and the lounge to be propped open. The addition of selfclosures was discussed with the registered manager and he undertook to seek advice from fire authority. A recommendation is made in respect of this. Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 24 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 X 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 2 3 X 2 X X 2 X Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 25 NO 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 YA9 Regulation 13 (4) Requirement The registered person must ensure that the risk assessments for residents are improved to include all relevant risks for each person, guidance for staff regarding the interventions that are in place, and those required to minimise the relevant risks. The registered person must ensure that at least 1 member of the staff team receives training in risk assessment. The registered person must ensure that all staff have up to date food hygiene training. The registered person must ensure that staff are provided with training in diabetes. The registered person must ensure that each resident have a health care plan. The registered person must seek alternative methods to provide weekend medication in order to avoid secondary dispensing of DS0000010653.V350148.R01.S.doc Timescale for action 30/01/08 2. YA9 13 (4) 18 (1) (c) 30/01/08 3. YA17 13 18 (1) (c) 18 (1) (c) 30/01/08 4. YA19 30/01/08 5. YA19 18 30/01/08 6. YA20 13 (2) 30/12/07 Sharon House Version 5.2 Page 26 medication by staff in the home. 7. YA34 19 Schedule 3 18 (2) The registered person must ensure that all staff personnel files include a recent photograph of the staff member. The registered person must ensure that that evidence of regular 1-1 supervision is maintained on people’s files. 30/01/08 8. YA36 30/12/07 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 YA5 YA6 YA9 YA39 Good Practice Recommendations It is recommended that the written documents concerning residents, such as contracts, care plans, risk assessments, and feedback forms be reviewed and improved to ensure that they are more person centred, and accessible to residents by the use of a larger typeface and simpler, more person centred language. It is recommended that the registered person apply for up to date CRB checks for staff whose CRB checks are more than 3 years old. It is recommended that an advocate be sought in order to provide independent support to residents in completing their feedback questionnaires regarding the quality of the service. It is recommended that the registered person seek alternative methods of propping doors open, ensuring the safety of people in the event of a fire. 2. YA34 3. YA39 4. YA42 Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sharon House DS0000010653.V350148.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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