Inspection on 14/07/05 for Sisha House

This inspection was carried out on 14th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sisha House 14/10/08

Sisha House 31/01/07

Sisha House 14/12/05

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 14 July 2005 9.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sisha House Address 124 Brondesbury Park London NW2 5JP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8459 3455 020 8621 9736 Mr Ramzanali Bhanji Mrs Nurejhan Bhanji Care Home 3 Category(ies) of OP 3 registration, with number of places Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02 March 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 G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday morning in July 2005 and lasted for 3 hours 30 minutes. The Inspector met each of the 3 residents and the member of staff on duty and would like to thank them, and the manager and the proprietor, for their comments. A partial site visit took place and selected records were inspected. The portfolio produced by the manager for her NVQ level 4 management training course was used during the inspection as it contained documents related to the running of the home. Both proprietors were present during the inspection. What the service does well: What has improved since the last inspection? Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 6 The statutory requirements identified and the recommendations made previous reports of the inspections that took place in 2004 have been addressed. Preset valves to regulate and control the temperature of the hot water leaving the taps have been installed. Documentation has been amended to include details of how to contact the CSCI. The manager has achieved an NVQ level 4 management qualification etc. 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 G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 standard(s) 6 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. EVIDENCE: The home does not offer an intermediate care service. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 Reviewing care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed and the manager needs to set these up on a monthly basis. Residents’ health care needs are met through access to health care services in the community, although dental appointments need to be arranged. Supporting residents to take their prescribed medication helps the residents to maintain a healthy lifestyle. Residents live in a home where they are shown respect and their privacy is maintained. EVIDENCE: Residents’ files were viewed. Care plans included goals/objectives and action to be taken. Weekly evaluations of the care plans have taken place. The care plans are formally reviewed on a regular basis but not reviewed by the home on a monthly basis. In order to involve the resident the format of the care plan needs to address the fact that 2 of the residents in the home do not speak English as a first language. The level of assistance required by residents, with personal care tasks varies and the manager provides both prompting and direct help. The manager said that the GP was contacted when a resident had problems with continence. The individual monthly weight charts for residents were available and they were up Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 10 to date. The manager was aware of the needs of the resident who was diabetic and the resident confirmed that they attended appointments at the diabetic clinic and with the optician. She confirmed that she had access to routing screening services, regular check ups with the GP and medication reviews. Another resident confirmed that the optician called at the home. However they had not had an appointment with the dentist recently and their dentures appeared to be loose fitting. Medication was kept in a locked facility. A system of monthly blister packs is used and a photograph of the resident is attached to the blister pack. The medication in the blister packs had been appropriately administered, prior to the inspection. One resident self medicates, with the agreement of the GP, and medication is kept in the resident’s room, under lock and key. Records were inspected and were up to date. Only one initial of the person administering medication is recorded. Residents are addressed in the manner in which they prefer. The name used for both elderly ladies means “mother” and this recognises their seniority and gives them respect. Each resident has their own single room, with ensuite facilities and they are able to enjoy time on their own if they wish without any unnecessary intrusion. A cordless telephone enables residents to make or to receive calls in private. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 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. The support of staff enables residents to maintain family contact. The right of residents to exercise choice is respected. Residents have a varied and balanced diet, with dishes to satisfy cultural needs. EVIDENCE: The manager said that one of the residents likes to accompany her on visits to cultural centres etc and that she accompanies the resident to the mosque on a Friday. The other two residents travel independently, using public transport. One resident said that they attend a cultural day centre from Monday to Friday and that they had taken part in a day trip to Brighton, which had been organised by the centre. Residents confirmed their use of community facilities including the library, cinema, cafes and pubs etc. One resident said that occasionally friends come to the home to visit them and the resident confirmed that visits took place in the privacy of their room and that the owners always made visitor welcome. Another resident has visits from their family and confirmed the welcome given by the owners. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 12 The manager said that she provides a “hotel service” for residents and that they are given a key to the front door so that they can have access to the home at all times. A resident confirmed that they are able to have their meals at the time they choose and that the time could vary from day to day, according to what they were doing. The manager said that each resident liked to have their evening meals at a different time and that as this was a “small home” they were able to support the residents’ 3 different lifestyles. There is a 4-week menu cycle and the current menu demonstrated a varied and wholesome diet. However one resident has particular likes and dislikes and the menu is amended to meet these. The resident confirmed that this is the menu that they wished to follow. The manager prefers to use fresh ingredients for meals and the other proprietor returned to the home at the beginning of the inspection after purchasing chicken for lunch for one of the residents. A vegetable curry with rice and chapattis was prepared for the other residents. There was a variety of fresh fruit and vegetables and a resident confirmed that with money provided by the manager the resident went to the local shops and selected fruit and vegetables which were later prepared for a meal. Residents confirmed that they enjoyed the meals served in the home. Meals are usually served in the open plan kitchen/dining/lounge area although a resident said that when they wished to eat their meal in their room they were able to. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 standard(s) 16, 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. The format should be one, which meets the needs of all residents. 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. It is recommended that the format of the procedure is reviewed as English is not the first spoken language for all of the residents. 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 the member of staff working in the home. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19, 20, 21 Residents enjoy a comfortable and homely environment with pleasant communal facilities. The home is located in the heart of the community and close to community facilities. Residents live in a home where standards of cleanliness are good. Bathing and toilet facilities are appropriately placed and afford residents their privacy. EVIDENCE: The residents were pleased with the location to the home, which is in within walking distance of the library, high street and transport facilities. They also said that they appreciated the size of their bedrooms and of the ensuite facilities. The areas seen during the inspection were clean and tidy. Communal facilities in the home consist of a large open plan lounge and dining area and a large open plan kitchen/dining and lounge area. One of the residents’ bedrooms is situated on the ground floor and the other 2 bedrooms are on the first floor. Each bedroom has ensuite facilities i.e. a toilet Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 15 and either a shower or a bath. In addition there is a toilet on the ground floor, close to communal areas and a bathroom, with toilet, on the first floor. Toilet and bathing facilities are sufficient for the 3 residents living in Sisha House and for the proprietors who live on the premises. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 There were sufficient staff on duty to support the current needs of the residents. Staff have the linguistic skills to communicate with residents and have knowledge of the cultural and religious needs of residents. Although this is a very small staff team the staff work very closely with the residents. 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. EVIDENCE: This is a home, which accommodates 3 residents, 2 of which enjoy going out in the day. The staff team is small and consists of the 2 owners, a member of staff and occasional cover provided by a family member. A rota was available. This is sufficient to meet the current needs of the residents. Staff are able to communicate with each of the residents in the resident’s first language. There is always a female on duty in the home to provide assistance with personal care. There are call bells in the each of the residents’ rooms and ensuite facilities. The call bells are connected to a portable console. The manager’s husband has been in contact with a college and is hoping to enrol on an NVQ level 2 training course in September 2005. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35, 38 A competent manager promotes the efficient and effective running of a care home. When quality assurance systems are in place the home ensures that the views of residents and their representatives are recorded but the views of residents must be expressed without assistance from those working in the home. Business plans help the manager to monitor the financial viability of the home and must be kept up to date. Insurance cover protects the welfare of residents, staff and visitors to the home and the home displayed a valid certificate. Residents’ finances are safeguarded by clear and complete accounts. The training that staff receive in safe working practice topics enables them to safeguard the health, safety and welfare of the residents. Regular maintenance of the property and of the fire precautionary systems assist in providing a safe environment for residents. EVIDENCE: Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 18 The manager has just completed her NVQ level 4 in Management qualification and the certificate was available for inspection. A copy of her job description was available. There are a number of certificates on file for both the manager and the proprietor, which demonstrate that they have undertaken periodic training to update their knowledge and skills. Quality assurance forms for completion by residents, in 2005, were available. The forms included questions about how complaints are dealt with, the care plan, the premises etc. There was also a questionnaire for relatives. It is recommended that the questionnaire for relatives is adapted so that professional visitors to the home can use it. The business plan, which had been drafted in 2004, was available. It included an analysis of overhead and capital costs, profitability, cash flow forecasting and the budget for March and April 2005. It needs to be kept up to date. There was a current insurance certificate in respect of public liability on display in the home. The records of money kept on behalf of service users were available for inspection. One resident receives their personal allowance each week and signs a receipt for this. The receipts were up to date. The other two residents draw what they wish and some money is spent on their behalf. An account of what is purchased and of its cost is recorded. There is a running total in respect of the balances held. Valves to regulate the temperature of hot water leaving the taps in the residents’ ensuite facilities have been fitted. A certificate was available for the testing of the portable appliances. The manager said that an electrician had installed new fuses and boxes and had checked the wiring in the house. She was waiting to receive the certificate. Copies of risk assessments for the building and in the event of fire were available. There was also a fire hazard analysis and a fire hazard action plan. There was evidence of regular fire drills taking place. Certificates were available to demonstrate that people working in the home had undertaken training in safe working practice topics. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x x STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 3 2 x x x 2 Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 20 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 8 Regulation 13.1 Requirement That residents are assisted to make dental appointments on a six monthly basis. That 50 of staff working in the home achieve an NVQ level 2 qualification. That the business plan is reviewed and updated on an annual basis. That a copy of the certificate for the wiring check etc is forwarded to the CSCI. Timescale for action 01 November 2005 and onwards 31 December 2005 01 January 2006 and onwards 01 November 2005 2. 3. 4. 28 34 38 18.1 25.2 13.4 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 7 Good Practice Recommendations That in addition to the weekly evaluations of the care plan and the six monthly reviews of the care plan and of the placement (involving family members and placing authorities) a monthly review of the plan is carried out by staff in the home so that changes in need can be monitored, addressed and recorded. That as English is not the first spoken language of all the residents the format in which the care plan is recorded is G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 21 2. 7 Sisha House 3. 4. 5. 9 16 33 6. 33 reviewed. That the person who administers medication records both of their initials on the medication record sheet. That as English is not the first spoken language of all the residents the format in which the complaints procedure is recorded is reviewed. That as English is not the first spoken language of all the residents the format in which the quality assurance questionnaire for residents is recorded is reviewed so that residents can complete these either on their own or with the assistance of someone who is independent of the running of the home. That the home develops a quality assurance questionnaire for use by professional visitors to the home. Sisha House G62-G11 S17426 Sisha Hse v227585 140705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 4th 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. 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