Inspection on 23/01/08 for Shrewsbury Road (267)

This inspection was carried out on 23rd January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shrewsbury Road (267) 29/01/09

Shrewsbury Road (267) 07/03/07

Shrewsbury Road (267) 30/01/06

Shrewsbury Road (267) 25/10/05

Shrewsbury Road (267) 20/12/04

Shrewsbury Road (267) 12/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Shrewsbury Road (267) 267 Shrewsbury Road East Ham London E7 8QU Lead Inspector Lea Alexander Unannounced Inspection 23 January 2008 09:30 rd Shrewsbury Road (267) DS0000022850.V356927.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 Shrewsbury Road (267) DS0000022850.V356927.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. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrewsbury Road (267) Address 267 Shrewsbury Road East Ham London E7 8QU 020 8586 7781 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sahara Homes (UK) Limited ** post vacant ** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user over the age of 65. Date of last inspection 7th March 2007 Brief Description of the Service: 267 Shrewsbury Rd is a residential home run by Sahara Homes (UK) Limited, which also runs similar homes in the area, and provides long term care and support on a 24 hour basis for four people with learning disabilities. The home states that its purpose is to support, encourage and enable each resident to realise their full capacity in choice, dignity, respect, privacy, independence, civil rights and individuality. The home is a large terraced house situated in a residential street in Forest Gate. Service users have single bedrooms with hand-basins. There is a kitchen/dining room, bathroom and shower room and a paved garden at the rear of the house. The home is within close proximity to East Ham and Green Street shopping areas and served by a range of bus routes, Upton Park and East Ham underground stations. Off-street and on-street parking is available. Current fees are in the range of £900-£1,200 per week. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of a day. During the course of the inspection the Inspector spoke with the staff and people who use the service. The Inspector also met with the Manager and examined paperwork and documentation relating to the running of the service. This included resident’s personal files and staff personnel files. This is a report about 267 Shrewsbury Road, a care home for adults with learning disabilities. An Inspector visited the home and spoke with people who live there and with staff. What the service does well: Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 6 People who live at the home told the Inspector that they “liked living here” and “got on well with staff”. Four women from a white British background live at the home. All the care staffs are women, and they come from a variety of cultural backgrounds. The home assesses the needs of potential residents. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 7 Residents have individual plans that are reviewed regularly. Staffs support residents to participate in a range of leisure and community activities. Residents enjoy the food and help choose the meals. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 8 Residents are well groomed and choose their own clothes and appearance. People who use the service are supported to attend a range of healthcare appointments. The home has a complaints procedure and residents know how to make a complaint. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 9 Each resident has their own bedroom that they can personalise The home is comfortable, pleasant and well maintained. Staffs are supported to undertake professional NVQ training. The home is properly insured and carries out health and safety checks. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 10 What has improved since the last inspection? Some residents sign their individual plans. The home has assessed residents to make sure the slope in the hallway is not a risk. Staffs have received first aid training. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 11 The home stores food safely. What they could do better: The home needs to update its statement of purpose. Resident’s plans should address all their needs. The times when residents have 1:1 supervision should be recorded in their plan. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 12 The home must demonstrate how residents are supported to make decisions. Potential risks must be assessed. Activities for residents should be more individualised. A variety of meals must be provided. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 13 The home must make sure that it has steps in place to deal with potential medical emergencies. The home must implement its action plan to safeguard people who use the service. The home must tell the Commission for Social Care Inspection of the outcome of its review of staffing levels. The home must carry out all checks on staff and volunteers before they start work. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 14 Staff should receive regular, paid training to help them do their jobs, and get regular supervision. A permanent Manager must be recruited. The home must ask people who use the service, their relatives and other interested parties about what it does well and what it could improve on. 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. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 15 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 Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 16 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has produced a statement of purpose, and potential residents are fully assessed. EVIDENCE: The Inspector viewed the homes statement of purpose. This requires revision to update the Managers details and to include the current contact details for the Commission for Social Care Inspection. There have been no new admissions since the previous inspection. Previous inspections have evidenced that the home carries out its own assessment prior to accepting new residents. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 17 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have individual plans that are regularly reviewed, however not all areas of need are addressed, and the homes risk assessment practises need to improve. EVIDENCE: The Inspector sampled the personal files for two people who use the service. This evidenced that each had an individual plan that addressed a range of social, personal and healthcare issues, however there were some areas of need that were not included. For example, continence management and occasions when they might need to use a wheelchair for one resident, and the frequency of blood sugar monitoring for another. One of the residents case tracked was also identified as having communication difficulties that could be more fully addressed. For example, the current plan states that the person can communicate but that this is severely impacted upon by a hearing impairment. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 18 The plan does not however identify strategies for communication with, or by the resident. The plans seen by the Inspector had been annotated to evidence their review at least every six months. However, the Inspector noted that where a change in need had occurred handwritten notes were added to the existing plan meaning that the plans were less easy to follow and held contradictory information. One resident had signed their plans to evidence their participation in the development process. The Manager showed the Inspector a new pictorial format for individual plans and advised that this would be introduced for each resident. The Inspector and Manager had a discussion about how the home could develop a more person centred approach in its individual plans, for example including information on past hobbies, activities or interests that could be followed up. The personal file for one person who uses the service included information on their family history. One person who uses the service is identified in their individual plan as requiring 1:1 support for certain periods during the week. However, it was not clearly recorded when these 1:1 sessions occurred. The Inspector requested that this information be supplied to the Commission for Social Care Inspection, but this was not received. Neither of the care plans sampled by the Inspector addressed issues of the person’s ability to give informed consent when presented with choices, and this is an area that requires development. Three people who use the service have their own bank or building society account and the fourth has an appointee who releases funds to the home for their day-to-day expenses. People who use the service receive help in managing their finances. This includes help in withdrawing cash from the bank or building society and having a personal allowance held by the home that residents can access when they need to. The home maintains a record of all monies received by people who use the service and withdrawals. Since the last inspection an anonymous complaint was received regarding the management of service users finances. As a result the London Borough of Newham carried out its own investigation and conducted several strategy meetings. The Inspector attended several of these meetings and also received copies of the findings of the local authorities investigations. These evidenced poor recording and accounting of service users personal allowances. The home acknowledged shortfalls in its practise and as a result Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 19 some unaccounted monies were reimbursed to service users and the homes accounting practises and procedures have been reviewed and revised. Sampling of records relating to the personal allowances of people who use the service during this inspection evidenced that new practise for recording and managing residents finances have been introduced. The home has also employed independent auditors to review the homes financial practises. The records sampled by the Inspector for two people who use the service during this inspection evidenced that the home maintains a record of the date and nature of each transaction that is signed by a staff member. Receipts for purchases are also retained. The monies available for two residents were found to correspond with the amount recorded in their individual logs. The home have weekly service users meetings, and the Inspector noted that some guidance notes for staff on the structure and topics for these meetings was pinned to the wall in the office, however sampling of the minutes of these meetings evidenced a limited range of discussions usually focusing around activities, shopping and the menu. The Inspector viewed the risk assessments available for two people who use the service. For one resident with complex needs only two potential hazards had been addressed, making a hot drink and mobilizing. For another person who uses the service a different risk assessment tool had been completed. This person was identified as self-medicating their insulin medication to manage their diabetes, but this was not subject to a risk assessment or management plan. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 20 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): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to engage in a range of community and leisure activities. However the home should develop a more individualised, person centred approach to the activities it organises. EVIDENCE: During the course of the inspection one person who uses the service was observed ironing. The resident also told the Inspector that they enjoyed being involved in household chores and liked to cook with staff support once per week. One person who uses the service seems to spend most days in the lounge with their “colour doodle”. They do attend church once per week and also attend the Gateway Club once per week. Their daily log also evidenced that they Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 21 have lunch out at least once per week, although the venue was not always recorded, this often seemed to be at another of the organisations care homes. This person is less physically able and has communication difficulties. The inspector noted that in the education and occupation section of their individual plan had been annotated to read “none required”. Sampling of the personal file and daily log did not evidence that the home engaged the resident in exploration around activities they might be interested in. A second person who uses the service told the Inspector that they like knitting and colouring in their picture book whilst in the home. They also said that they liked attending the Gateway club each week. This resident also told the Inspector that they would like to attend a day service and commented that they sometimes got “bored” as they would like to go out in the community more, but that there were not always enough staff to allow this. A third person who uses the service attends a day service three days per week, and they told the Inspector that they enjoyed this very much. They also attend weekly physiotherapy sessions that included use of a trampoline. A fourth person who uses the service attends a day service four days each week as well as the Gateway club once per week. They also like to go shopping at the weekends. Whilst people who use the service engage in a range of community and leisure activities case tracking evidenced the need for the home to develop more individualised, person centred activities. Discussion with people who use the service, with the Manager and staff and viewing of individual plans evidenced that residents are supported to maintain contact with their families. The home also has links to a local resident who has befriended the homes residents. The volunteer visits the home regularly and spends times individually and collectively with people who use the service. During the course of the inspection people staff were observed talking and interacting with residents. People who use the service were observed choosing when to be alone or in company. Discussion with people who use the service and the Manager evidenced that residents participate in the choice of meals, through informal discussion and as a standing item at residents meetings. Both people who use the service who the Inspector spoke with said that they enjoyed the meals provided very much. The Manager commented that residents seemed to particularly enjoy their roast dinner each Sunday. The Inspector viewed the logs of meals provided for the last three months, and noted that the weekly menu provided appeared to change very little. The Inspector also noted that whilst evening meals were recorded, lunch was often recorded as “own choice” with no other information available. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 22 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. 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 supported and encouraged to manage their personal care. Medication records are up to date and some residents administer their own medication. However, self-medication was not occurring within a risk assessment framework, and there was no recording to evidence how residents had been supported to make decisions about some healthcare decisions. EVIDENCE: The Manager advised the Inspector that one resident requires assistance with personal care whilst others are more independent, and require only prompts or reminders. Discussion with two people who use the service evidenced that they choose their own clothes, and that their appearance reflects their personality. Sampling of the personal files for two people who use the service evidenced that residents are supported to access and attend a range of healthcare Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 23 appointments including GP check ups, dentist, optician, district nurses, chiropodist and occupational therapist. One person who uses the service had recently undergone surgery for a cataract operation. The Inspector viewed their personal file and also spoke with the Manager and Responsible Individual. It was not evidenced that the person had understood or given their consent to the procedure, and an advocate had not been involved. There were no notes to evidence how the decision to agree to the surgery had been made, and whether other parties had been consulted. The home has produced a medication policy and procedure that was viewed by the Inspector. It includes information on self-medication, and guidance to staff relating to the administration and handling of medicines. The Inspector examined the available medication and Medication Administration Records (MAR) for two people who use the service. All available medications were listed, and the MAR sheets were found to be in good order. The Manager advised the Inspector that one person who uses the service partially self medicates with insulin to manage their diabetes. This was reflected in their individual plan but was not risk assessed. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 24 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and residents know how to make a complaint. Some shortfalls in the homes safeguarding practises have been identified. The home has acknowledged this and has developed an action plan to address these. EVIDENCE: The Inspector viewed the home complaints policy. This included contact details for the Commission for Social Care Inspection and clearly stated that the home aimed to investigate and respond to complaints within a 28-day timescale. The Inspector was advised that the no complaints had been received, but that the home had developed a proforma for recording any complaints received, including the nature of the complaint, the investigation undertaken, outcome and action taken. Both residents spoken to by the Inspector said that if they were unhappy with anything they would tell a staff member. The home has developed an adult protection policy and procedure. This includes definitions of abuse and descriptors of the types of abuse vulnerable Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 25 adults may experience. The policy makes appropriate reference to local safeguarding multi agency protocols. As stated earlier in this inspection report, a number of anonymous adult protection allegations have been made regarding the management of resident’s findings. Several strategy meetings were held and an audit undertaken. This highlighted poor recording practises with regards to resident’s monies. The home has produced its own action plan to address identified shortfalls, including its own audit, revision of policies and procedures and staff training. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a comfortable, homely environment that is well maintained. Each resident has their own bedroom that they have been encouraged to personalise. EVIDENCE: The home is situated in a large terraced house. There is a large entrance hall with a communal lounge off of this. The lounge has a range of comfortable seating and there is a TV and stereo. The walls are decorated with pictures of residents. One resident’s bedroom is located on the ground floor, along with a shower room with WC and hand basin. A large kitchen diner with access to the garden is also located on this level. From the hallway there is access to a large cellar that is used for general storage including canned goods and a large freezer. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 27 Access to the first floor is via a staircase and on the upper level 3 service users bedrooms, and two small offices are located as well as a bathroom with a tub and mixer taps, WC and hand basin. Two people who use the service showed the Inspector their bedrooms. These were found to be comfortably furnished with a bed, wardrobe and chest of draws. Residents had also been supported to personalise their bedrooms to reflect their own lives and personalities. During the course of the inspection the homes premises were noted to be clean, hygienic and free from offensive odours. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 28 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffs are supported to undertake external professional training, however the home needs to develop its own core-training programme. A review to ensure that sufficient staff is on duty at all times is currently on way. EVIDENCE: The staff on duty at the time of the inspection advised the Inspector that they had received first aid training. The Manager advised the Inspector that all staff within the home has obtained NVQ level 2, and are now studying for NVQ level 3. The Inspector asked to see the homes current staffing rota. This was not available on site, but a copy was printed off by the Manager and bought to the home later in the day. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 29 The staffing rota seen by the Inspector identified a new member of staff as being on site as part of their induction. This was not the case, and the Inspector was advised that they were in fact shadowing staff at a different home that day. Discussions with the Manager and sampling of the rota evidenced that the Manager is on site for one and a half days and on call for the remainder of the week. The home employs one senior support worker and four support workers. There is usually a single member of staff on duty, and a single member of sleeping staff covering the night shift. The Inspector was advised that a review of the homes staffing levels was currently underway. The Inspector viewed the personnel files for two staff members. This evidenced that the home had obtained an enhanced level Criminal Records Bureau check for each. However, for one staff member only one reference was available. Sampling of the personnel files also evidenced that the home issues staff with copies of their employment terms and conditions. The Inspector noted that the home has a volunteer policy that states all volunteers will be subject to a Criminal Records Bureau check, however the Manager advised the Inspector that this had not been done. The Manager advised the Inspector that at present there is no system for involving people who use the service in the selection of staff, but that there feedback is obtained when staff undertakes their probationary period. Sampling of personnel files for two staff also evidenced that each had completed an induction to the home. The Inspector sampled the available training records for two staff members. These evidenced that one staff member had attended a range of training in the last year including adult protection, medication and health and safety. However a second care worker was evidenced as having received only medication training in the previous year. One of the sampled care workers was also evidenced as having completed learning disabilities and challenging behaviour courses in 2003 and 2005, however there was no evidence of staff receiving ongoing training specialising in learning disability. The Inspector examined the supervision records for two care workers. These evidenced that one care worker had received supervision on two occasions in the previous 12 months, and a second had received supervision on four occasions in the preceding year. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 30 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally has good health and safety practises. However, there is no permanent manager in post and no recent quality assurance exercise. EVIDENCE: The previous registered Manager left the home in October 2007. At present a former Deputy Manager is the acting manager on a part time basis. The Responsible Individual advised the Inspector that they had advertised and interviewed for the Managers post without success and were now considering permanently appointing the acting Manager and considering what support and development they might need to fulfil the role. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 31 The acting Manager has completed NVQ level 3 and has previously worked within the organisation as a Deputy Manager. They have several years experience prior to this as a support worker. The Manager advised the Inspector that the home does not currently carry out an annual survey of residents, their families or professionals, and no published quality assurance information was available for the Inspector to see. The Inspector was subsequently shown completed surveys by residents for 2006, but these had not been collated or published and no recent surveys had been completed. The Inspector examined a range of records relating to health and safety. These evidenced that fridge and freezer temperatures and checked and logged daily. The temperatures recorded were within acceptable limits. The home carries out weekly tests to ensure that water temperatures remain within appropriate parameters. The home was evidenced as carrying out weekly fire tests when all detectors are checked, and all fire appliances have service records. The home also has a current Portable Appliance Testing (PAT) certificate. The Inspector viewed the homes accident and incident logs and noted an incident recorded when a resident had developed hypoglycaemia. This had occurred when there had been a singleton member of staff on duty. Appropriate sugary food items were not available on site to administer immediately to the resident, and several telephones had been made before the appropriate food items were bought to the house. The home displays a current insurance certificate with appropriate cover. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 32 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 3 Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? No. 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 YA1 Regulation 4, 5 & 7 Requirement The homes statement of purpose must be updated to include the current Managers details and contact details for the Commission for Social Care Inspection. Resident’s individual plans should address the full range of their social, personal and healthcare needs. Where there is a change in need a new care plan should be produced rather than notes added to the old plan. The home must clearly identify any periods of 1:1 supervision for residents, and evidence that this is provided. 3. YA7 12 The home must demonstrate 30/06/08 how individual choices have been made; and record instances when others have made decisions and why. Potential risks must be subject to 30/06/08 an assessment and management DS0000022850.V356927.R01.S.doc Version 5.2 Page 34 Timescale for action 30/06/08 2. YA6 15 30/06/08 4. YA9 13 Shrewsbury Road (267) strategy. A uniform risk assessment tool must be used within the home. 5. YA14 16 The home must develop more individualised person centred activities for people who use the service. The home must maintain a log of all the meals provided. A variety of meals must be provided. 7. YA19 12 The home must ensure that appropriate procedures are in place to address healthcare needs, for example sugary foods must be available if a diabetic resident enters a hypoglycaemic state. The home must evidence that residents are supported to make decisions about their own healthcare and medical treatment. For example, the decision to undergo cataract surgery. 8. YA20 13 Self-medication must be subject to a risk assessment and management plan. The home must implement its action plan to safeguard people who use the service. An accurate staffing rota must be available on site at all times. The home must notify the Commission for Social Care Inspection of the outcome of its review of staffing levels. 30/06/08 30/05/08 30/06/08 6. YA17 13 & 16 30/06/08 9. YA23 13 30/06/08 10. YA33 18 30/06/08 Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 35 11. YA34 19 The home must obtain two satisfactory references for employees. The home must fully implement its volunteer policy and procedure and obtain a Criminal Records Bureau check for each volunteer in contact with residents. 30/06/08 12. YA35 18 The home should provide specialist learning disabilities training to enable staff to better meet the needs of people who use the service. All staff must be evidenced as receiving at least five days paid training per year. 30/06/08 13. 14. YA36 YA37 12 & 18 8&9 Staff must receive a minimum of six supervisions in a year. A permanent Manager must be recruited, and they should apply for registration with the Commission for Social Care Inspection. The home must obtain the views of people who use the service and other stakeholders. The outcomes of quality assurance should be collated and made available to interested parties. 30/09/08 30/06/08 15. YA39 24 30/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 36 No. Refer to Standard Good Practice Recommendations Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shrewsbury Road (267) DS0000022850.V356927.R01.S.doc Version 5.2 Page 38 - 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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