Inspection on 18/07/07 for Sitara Haven

This inspection was carried out on 18th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sitara Haven 12/09/06

Sitara Haven 10/04/06

Sitara Haven 30/09/05

Sitara Haven 12/04/05

Sitara Haven 26/08/04

Sitara Haven 13/04/04

Sitara Haven 18/12/03

Sitara Haven 03/07/03

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Sitara Haven 23 Hambrough Road Southall Middlesex UB1 1HZ Lead Inspector Ms Susan Woolnough-Singh Key Unannounced Inspection 18th July 2007 10:00 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 Sitara Haven DS0000027715.V341257.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. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sitara Haven Address 23 Hambrough Road Southall Middlesex UB1 1HZ 0208 867 9590 0208 893 5342 sitarahaven@aol.com 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) Mrs Rajinder Hunjan Mrs Rajinder Hunjan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user, who has been diagnosed as having a mental illness, remains living in the home for as long as there is no deterioration which affects the well being of other service users, as agreed by the Commission For Social Care Inspection, on 1st December 2005 The home must inform CSCI when the service user no longer resides at the home. 12th September 2006 Date of last inspection Brief Description of the Service: Sitara Haven is a terraced house, located in a quiet residential street close to the shops and amenities of Southall. There are bus services close by and Southall Station is within walking distance. The home is registered for three people with learning disabilities. There is, however, a variation to the conditions of registration to accommodate a service user with mental health difficulties. The home is owned and managed by Mrs. Rajinder Hunjan and she and her family live on the premises. There are three bedrooms, one on the ground floor and two on the first floor. There is a shower room and toilet on the ground floor, and a bathroom with a toilet on the first floor. The communal facilities are shared with the owner’s family. One lounge, which is also the dining room, overlooks the garden. The other is situated in an interior room, without windows, on the ground floor. The kitchen and office are located on the ground floor. The current staff team comprises of the Registered Provider/Manager and three support staff. As well as providing permanent accommodation for up to three service users, the home provides respite care at weekends when the permanent places are not filled. There are also day services provided for one person who shares the same communal facilities with the people who live at Satara Haven. The cultural needs of the service users are being appropriately met. The current fees in the home range from £550 to £888 per week. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Sitara Haven. All of the Key National Minimum Standards for Younger adults were assessed. As part of the inspection process the inspector spoke with three people living at Sitara Haven. The Inspector toured the building spoke with staff and examined care records, staff records and health and safety records. At the last inspection, which took place on 12th September 2006, seven statutory requirements were made, improvements had been made and six had been complied with. Further work needs to be carried out on demonstrating the views of people who use the service. What the service does well: What has improved since the last 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. The summary of this inspection report can be made available in other formats on request. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 6 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 Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 7 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): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information for people who use the service has been improved since the last inspection. EVIDENCE: A requirement was made at the last inspection for the Statement of Purpose to be updated and include information on the impact of Day Services on the people who live at Satara Haven. The Inspector saw the new version of the Statement of Purpose this had been amended and include brief information on the use of the home for Day Care Services. A recommendation was also made that the Statement of Purpose, when updated, should be presented in a format that would specifically suit the needs of people who live at Sitara Haven, the format had been changed and included pictures and clear, precise information. It is to be further recommended that the Statement of Purpose alterations be completed and a copy of the new version be forwarded to people who use the service and the Commission for Social Care Inspection. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 8 Since the last inspection no new people have moved into Sitara Haven. Assessment of people’s care needs is carried out by the placing Local Authority and kept on the care file. A requirement of the last inspection was that people be provided with up to date information on the fees and services. A letter was forwarded to all the people who live at Sitara Haven with this information; the Inspector saw a copy of this. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 able to make decisions about their daily lives. People have care plans that demonstrate that their basic daily needs have been considered. Person centred planning needs to be incorporated into the care plans. EVIDENCE: At the time of the inspection there were three people residing permanently in the home. A requirement made at the last inspection stipulated that care plans must be up to date, this was the case for one file examined, one care plan was dated July 2006. Basic information contained in the care plan sets out how people’s daily needs will be met. People who use the service must be given the opportunity to develop person centred plans with staff. Two people were at home on the day of the inspection both of who confirmed that they are able to make decisions about their daily lives and were seen to do so. Goals and personal aspirations must be defined in the care plan. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 10 One person attends a Day Service and travels independently, two people are not independent and need to be accompanied by staff, and the reason for this was explained to the Inspector. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 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 have opportunities for participating in the leisure and lifestyle activities they prefer and are part of the local community. EVIDENCE: People living at the home confirmed that they are given the opportunity to participate in the activities that they prefer. People have a number of interests such as listening to music, shopping, going to the cinema to see Bollywood and English films, and eating out locally. One person visits the library frequently to read Asian language newspapers and books. The staff and the people who use the service go on holiday once a year to the Channel Islands. The home is located in the centre of Southall within a few minutes walking distance of the Broadway. Places of worship are close to the home; including Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 12 the Sikh Gurdwara and Hindu Temple. People who use the service choose whether or not they wish to attend religious worship. The Inspector spoke with people who use the service and staff about contact with family. Family relationships are maintained and two people have relatives who visit regularly and with whom they go out. The day of the inspection was the day prior to the Ealing and Southall byelections. One person in discussion was able to state a preference of political party. The Inspector was informed that two people would be accompanied to the polling station if they wished to vote. The menu reflected a variety of meals, which include Asian and English. Both English and Indian breakfast is on the menu and Indian food predominates on the menu for the evening meal. A record of the meals taken is made. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are being supported by staff to access both the health facilitated and their specialist medical health needs. The medication administration system was satisfactory. EVIDENCE: Support for personal care is provided in line with each person’s individual needs. People who use the service may need some prompting in this area. Evidence was seen on the two care files that health care needs are being monitored. Recent visits had been made to the Dentist; a record of visits to the General Practitioner is also made. A condition of registration is that one named person diagnosed as having mental illness can be accommodated. There was evidence on this person care files of support from the Community Mental Health Team and Psychiatrist. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 14 Staff have received training in the safe administration of medication, this took place in April 2007. People are not responsible for the administration of their own medication. The medication cabinet and medication administration records were checked and no concerns were noted. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 15 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. People spoken with indicated that they were satisfied with the service. However, it is recommended that further work be seen to be carried out to ensure they are aware of the complaints procedure. Staff in the home assists people to manage their finances. The assisted financial transaction records of two people were seen. Further information is required from the Registered Manager on the plans that have been made for the training of staff in the protection of vulnerable adults. EVIDENCE: A complaints procedure for people who use the service is available. The telephone number for the Commission for Social Care Inspection should be added to the complaints procedure. No complaints had been recorded in the home since the last inspection. It is to be recommended that the amended complaints procedure be issued to people who use the service. There have been no adult protection issues in the home since the last inspection. The training plan provided to the Inspector indicated that in house training on adult abuse is due to take place in September 2007. No Specific date is stated. The Registered Manager must forward the date of this with a plan of the areas covered by this training to CSCI by the end of September. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 16 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, 25, 26,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is located in a convenient part of Southall close to shops and public transport. The home is kept in a reasonable condition for the benefit of people who use the service. The situation with regard to Sitara Haven being used for day care needs to be monitored and CSCI informed of any changes. EVIDENCE: There have been no major changes to the environment since the last inspection. The home is shared by the Registered Managers family and the people who use the service. The Registered Manager and her family have sleeping accommodation in a loft conversion. There are three bedrooms on the first floor for people who use the service these were clean and functional. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 17 People who use the service and the Registered Managers family share the communal areas of the home. There are two lounges only one of which is acceptable for the purposes of providing care. The conservatory/lounge to the rear of the building is pleasant. There is a large dining table and seating areas. A wide screen television is available with Asian Network programmes. This room looks out onto the back garden. The other lounge is an internal room between the hall and the rear lounge; there are no windows in this room. There are sofas and a television; this room was not used on the day of the inspection. The Inspector did observe that the two sofas in the rear lounge were of faux leather and some of the seating was split. The quality of furnishings needs to be improved for this standard to be met. The home was being kept in a clean and hygienic condition. A new structure had been built in the back garden. This was a solid structure that looked like a detached extension. When asked the Registered Manager said this was to be a playroom and a storeroom. The back garden was unusable, as building rubble had been left. The Registered Manager said that the building works would be completed shortly. A requirement of the last inspection was that the Registered Manager must provide information on the number of people being offered day care at Sitara Haven as this would impact of the space available. At the time of the inspection one person was receiving day care on a Friday afternoon. It is recommended that the Registered Manager inform the CSCI of any changes to this schedule. . Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 18 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): 32,24 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At the time of the inspection there were sufficient numbers of staff to meet the assessed needs of people who use the service. Staff are undertaking NVQ training to ensure that they are skilled and competent. Further information is required on the dates for planned training in 2007. EVIDENCE: The staff team consists of the Registered Provider/Manager and three care staff. One care staff is a family member and two are employed. There is a fourth member of staff who works as a relief worker occasionally. The two permanent care staff work in the home on a part time basis. As a minimum, one member of staff is on duty at a time. The personnel files of two members of staff were seen to assess recruitment procedures. Application forms, two references and CRB checks were on file. It is to be recommended that all gaps in employment history are accounted for Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 19 where possible. There was evidence of a tick box appraisal for staff on file these were completed in 2006. The two permanent members of staff are undertaking an NVQ level 2 at Thames Valley University. Training in Diabetes, smoking and mental health has been planned for November 2007. The CSCI needs to be informed of the dates for this training. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Consistency has been provided for people who use the service as there have been no changes to the staff team. Staff have received satisfactory training in health and safety matters. Further work needs to be carried out to complete an improvement plan for the home. EVIDENCE: There have been no changes in management and staffing since the last inspection therefore offering stability for people who use the service. A good rapport was noted between staff and people who live at the home. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 21 Although information on quality monitoring is available in the home an improvement plan based also on the opinions of people and the representatives was not available. This has been a requirement of previous inspections. A requirement was made at the last inspection for Legionella testing to be carried out, this had been done. Staff had received training in health and safety related subjects. Three staff had First Aid training. Training in food hygiene, health and safety, fire training and moving and handling had taken place in 2006/7. Electrical testing had taken place in June 2006. A fire safety policy and fire risk assessment have been completed. The fire risk assessment should be updated as this was dated February 2006. A risk assessment needs to be undertaken with regard to the building work and the building materials deposited in the garden. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 X 4 x 5 3 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 2 25 3 26 3 27 x 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 2 x Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 23 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) Requirement Timescale for action 01/10/07 2. YA23 12 (a) 18 (1) 23 (2) (b) 24 3. 4. YA24 YA39 The Registered Manager must ensure that the service user plan is kept under review and that the service users goals and aspirations are contained in the plan. The Registered Manager forward 01/09/07 the date that staff are to receive training in the protection of vulnerable adults. The Registered Manager must 01/10/07 ensure that seating provided is of an adequate standard. The Registered Manager must 01/10/07 ensure that a report of the quality of service, including consultation with people and their representatives be provided to CSCI (Previous timescale of 30/11/06 not fully met) An assessment of risk to people who use the service must be carried out with regard to the ongoing building work in the back garden. The fire risk assessment must be reviewed to incorporate any changes in the home. DS0000027715.V341257.R01.S.doc 5. YA42 12 (a) 20/08/07 6. YA42 12 (A) 01/09/07 Sitara Haven Version 5.2 Page 24 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. 1. 2. Refer to Standard YA1 YA23 YA22 Good Practice Recommendations The amended Statement of Purpose must be supplied to people who use the service. The phone contact details for CSCI should be contained in the complaints procedure. That the staff team encourage service users to understand more fully the procedures for making their concerns and complaints known. Sitara Haven DS0000027715.V341257.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!