Inspection on 14/12/05 for Sisha House

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Sisha House 14/10/08

Sisha House 31/01/07

Sisha House 14/07/05

Sisha House 02/03/05

Sisha House 27/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Sisha House 124 Brondesbury Park London NW2 5JP Lead Inspector Julie Schofield Unannounced Inspection 14th December 2005 09:20 X10015.doc Version 1.40 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 Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 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 Older People. 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. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Sisha House Address 124 Brondesbury Park London NW2 5JP 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) 020 8459 3455 020 8621 9736 Mr Ramzanali Bhanji Mrs Nurjehan Bhanji Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: Sisha House is a care home, which provides personal care for 3 elderly persons. All service users enjoy their own single bedroom and each bedroom has en-suite facilities. There is sufficient communal space for service users and for the proprietors who live on the premises. There is also a very large open plan kitchen and dining area. The house is just off Willesden High Road with its shops and transport connections. It is within a couple of minutes walk of Willesden Library. The home has off street parking spaces at the front of the property. Although a busy area there is street parking within a 5-minute walk from the home. The home has a well-maintained garden at the rear of the premises. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Wednesday morning in December 2005. It started at 9.20 am and finished at 11 am. The Inspector met 2 of the 3 residents. The third resident was having a lie in and did not wish to take part in the inspection. The Inspector would like to thank the proprietors, the domestic and the residents for their comments during the inspection. A partial site visit took place and selected records were inspected. Progress towards compliance with statutory requirements identified during the previous inspection in July was checked. What the service does well: What has improved since the last inspection? Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 6 Two statutory requirements were identified during the last inspection in July 2005 and have been complied with. Residents are now assisted to make dental check appointments on a regular basis. A copy of the current certificate for the electrical wiring installation check was now available for inspection. What they could do better: 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. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were not inspected. EVIDENCE: No new residents have been admitted to the home since the setting up of the CSCI and prior to this the setting up of the NCSC. The home does not offer an intermediate care service. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 Reviewing care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed. Residents’ health care needs are met through access to health care services in the community. Supporting residents to take their prescribed medication helps the residents to maintain a healthy lifestyle. The home demonstrates this through accurate recording of the administration of medication to residents. EVIDENCE: A discussion took place with the manager regarding 2 recommendations made during the previous inspection in July 2005. It was recommended that in addition to weekly evaluations of the care plan and six monthly reviews of the plan (and placement in the home) the home review the care plan on a monthly basis to monitor any changes to the needs of the resident. A record of the monthly reviews was available. It was also recommended that as English is not the first language of 2 of the residents that a suitable format for the care plan is developed to meet the needs of each resident. The manager said that either she or her husband would be able to verbally translate the care plan for each of the 2 residents, either into Gujarati or Karchi. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 10 A statutory requirement was identified during the previous inspection in July 2005 that residents are assisted to make dental check appointments were on a regular basis. This was overdue for one resident and the reasons for this were discussed. Since the last inspection the resident has agreed to go to the dentist and has now been fitted with a new set of dentures. The resident has also had an annual home visit from the optician and as a result of this has been prescribed a pair of new glasses. Another resident confirmed that if they were unwell an appointment was promptly made with the GP. They said that they had visited the GP yesterday. The resident confirmed that they had had the flu jab and the manager said that all the residents had agreed to have this. A recommendation was made during the previous inspection in July 2005 that the person who administers medication records both of their initials on the medication record sheet. The medication records were available for inspection. Both the initials of the person administering medication had been recorded. The records were up to date and complete. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 Taking part in activities, particularly in the community, gives residents the opportunity to become more independent and to enjoy an interesting and stimulating lifestyle. Residents have a varied and balanced diet, with dishes to satisfy cultural needs Standards 13 and 14 were inspected during the previous inspection in July 2005. EVIDENCE: The manager said that there are no rules as such in the home and that residents were able to do as they pleased. Residents are able to follow their interests and 2 residents like to go out each day. One resident likes to go to the library and the other resident likes to go to a cultural day centre and to the cinema. Mealtimes are flexible to accommodate the residents’ activities. Within the home residents said that they are able to pray in their rooms and their privacy is respected. The resident confirmed that the day before the inspection the manager had taken them to an important day of celebrations at the mosque. Some friends of the resident were visiting London for the week and the resident had invited them to have lunch in the home on one of the days. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 12 A discussion took place with 2 of the residents. There are 2 menus for the home. One resident has particular likes and dislikes and his menu has been amended to include these. The other 2 residents are Asian and the menu meets their religious and dietary needs. One of these residents is diabetic. Fresh ingredients are used for meals and one of the residents said that they choose the vegetables on a daily basis when they go out. The manager reimburses them for their purchases. There was a variety of fresh fruit in the dining room and vegetables in the kitchen. Residents confirmed that they enjoyed the meals served in the home. During the inspection a meal was being prepared and it looked and smelt appetising. Meals are usually served in the open plan kitchen/dining/lounge area although one resident prefers to eat their meal in their room, and this is respected. Mealtimes are flexible to meet the needs of residents. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 There is a complaints policy in place to protect the rights of residents and a resident said that they knew whom to talk with if they had a problem. Residents’ legal rights are protected. An adult protection policy and protection of vulnerable adults training for staff contribute towards the safety of residents. EVIDENCE: The home has a complaints procedure in place and it includes information on how to contact other agencies e.g. the CSCI. The manager said that no complaints have been recorded since the last announced inspection. She said that she speaks to each resident on a daily basis and encourages him or her to give feedback. A resident confirmed that if they had a problem they would speak to the proprietors. A recommendation was made during the previous inspection in July 2005 that the format of the procedure is reviewed as English is not the first spoken language for all of the residents. The manager said that either she or her husband would be able to verbally translate the complaints procedure for each of the 2 residents, either into Gujarati or Karchi. Residents are able to vote if they wish and the manager said that all of the residents’ names are entered on the electoral roll. She said that at the last election one resident returned a postal ballot form and another resident was escorted to the polling station. Although the home receives the personal allowance on behalf of the 3 residents, the residents choose whether to receive Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 14 this in total or to receive this in several smaller amounts. All residents spend their money as they wish. The home has an adult protection procedure in place and it includes a link to the local authority guidelines for the protection of vulnerable adults. Copies of these were available. The manager said that no allegations or incidents of abuse have been recorded since the last announced inspection and was clear about reporting lines in the event of any allegation or incident. The manager has attended protection of vulnerable adults training and said that they have cascaded this information to her husband and to the domestic member of staff working in the home. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Residents live in a clean and hygienic environment. Standard 19 was inspected during the previous inspection in July 2005. EVIDENCE: The areas that were inspected were clean and tidy and free from offensive odours. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 30 Residents benefit from a service provided by people whose work practice is based on an understanding of the needs of the client group. NVQ training for the staff working in the home would develop and enhance this. The proprietors undertake training so that they are able to recognise and respond to the changing needs of the residents. Standard 27 was inspected during the previous inspection in July 2005. Standard 29 was not inspected. EVIDENCE: A statutory requirement was identified during the previous inspection in July that 50 of carers achieve an NVQ level 2 qualifications. The timescale for action was the 31st December 2005. Mr Bhanji said that although he has enrolled for a course he would not complete this by the end of December 2005. His NVQ level 2 and 3 candidate handbook was produced. An extension to the timescale was agreed. Sisha House is a home accommodating 3 residents. The proprietors are assisted in the provision of a service by a domestic. This person has been employed in the home for several years and no new staff have been employed since their appointment. This is a home accommodating 3 residents where the proprietors are the joint carers. They have been running the home for many years. There are Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 17 certificates demonstrating their attendance at training courses, both new areas of training and refresher courses. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 38 Business plans help the manager to monitor the financial viability of the home and must be kept up to date. Regular maintenance of the property and of the electrical wiring installation assists in providing a safe environment for all people living on the premises. Standards 31, 33 and 35 were inspected during the previous inspection in July 2005 EVIDENCE: A statutory requirement was identified during the previous inspection that the business plan is reviewed and updated on an annual basis. The timescale for action is the 1st January 2005, which has not yet expired. The manager said that they are updating this at present. A statutory requirement was identified during the previous inspection that a copy of the certificate for the wiring check etc is forwarded to the CSCI. This Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 19 was done and the original certificate was available in the home and was dated 10/5/03. It was valid for a period of 5 years i.e. next inspection due in 2008. Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X X X 3 Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP28 Regulation 18.1 Requirement That 50 of staff working in the home achieve an NVQ level 2 qualification. (Previous timescale of 31 December 2005 not met). That the business plan is reviewed and updated on an annual basis. Timescale for action 01/09/06 2 OP34 25.2 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sisha House DS0000017426.V269979.R01.S.doc Version 5.0 Page 23 - 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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