Inspection on 12/05/05 for Sophia Care Home

This inspection was carried out on 12th May 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

Sophia Care Home 30/10/07

Sophia Care Home 21/07/06

Sophia Care Home 15/11/05

Sophia Care Home 28/02/05

Sophia Care Home 21/10/04

Similar services:

Ashlong House

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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 Sophia Care Home 236 Malvern Avenue South Harrow Middleseex HA2 9HE Lead Inspector Sue Mitchell Announced 12 May 2005 09:45 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Sophia Care Home Version 1.10 Page 3 SERVICE INFORMATION Name of service Sophia Care Home Address 236 Malvern Avenue South Harrow Middlesex HA2 9HE 020 84260 8110 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) Ms Sophia Mirza Ms Sophia Mirza CRH 5 Category(ies) of LD - 5 registration, with number of places Sophia Care Home Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28.2.05 Brief Description of the Service: Sophia Care Home is care home for adults with learning disabilities. It is situated in a quiet residential area of Eastcote. It is close to local shops and transport. It is a two -story conversion of two semi- detached houses into one five-bed home on two floors. There are five single bedrooms and two bathrooms on the first floor and a spacious communal lounge and dining area, large kitchen and laundry area for the service users. There is a well maintained garden to the rear of the house. The house is part of the normal housing stock in the same road. The manager has converted the large communal areas into a day care facility for peole with learning disabilities, which is separate to the residential home. Sophia Care Home Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out during the morning and early afternoon when the resident was at home. The manager and a male member of staff were on duty. The inspector spent some time with the resident discussing his activities and life in the home. The staff member and manager also discussed the resident’s needs in detail with the inspector. The inspector reviewed the requirements from the last inspection and looked at care plans, health care and other records, medication and health and safety matters. What the service does well: What has improved since the last inspection? What they could do better: There were no requirements from this inspection, which is commendable. Some of the requirements set at the last inspection had not been met in full. These were related to staff person specifications and terms and conditions of employment and were discussed with the manager who agreed to complete them within the stated timescales. The manager is to develop her quality assurance system, which will be assessed at the next inspection. Sophia Care Home Version 1.10 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sophia Care Home Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Sophia Care Home Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2 Prospective residents and their relatives are given clear information on the services and facilities provided by the home, which is written in a user- friendly format. Residents are involved as much as possible in their assessment prior to admission EVIDENCE: The home had been required to improve its service user guide to make it more accessible to them. This has now been achieved. The manager said that the current resident is able to read and had preferred the previous document. The format may need to be reviewed should there be new residents coming in who are unable to read. There was detailed information on the resident who was in the home. The manager had been required to ensure that all needs identified during the meetings at the beginning of his stay be recorded on the care plan. This had been achieved. Sophia Care Home Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Residents’ and relatives are able to be involved in meetings and reviews about their care needs. Care plans are detailed and reflect how the staff are to support the resident in achieving their goals. Risk assessments reflect the level of independence the residents have within the home and out in the community. EVIDENCE: There has been a distinct improvement in the care planning and risk assessment records since the last inspection. They are more detailed with clear information for staff on how they are to support the resident to achieve their goals. They have been regularly reviewed and monthly summaries are now being written. Staff described how they discussed particular issues in carrying out daily routines with the resident with him to ensure that he maintains a good level of personal hygiene. They also said they discussed and plan the next day’s activities with the resident to ensure he is clear about what he has chosen to do. The resident said the staff support and help him plan his daily activities. Risk assessment had been updated since the last inspection to reflect the resident’s needs, both in house and out in the community. Sophia Care Home Version 1.10 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 The resident is able to choose what he would like to do on a daily basis both in the home and in the community. The resident is able to contact his family whenever he chooses. EVIDENCE: The resident informed the inspector that he has a daily routine which includes a daily walk to the shops and also out to visit museums and other places of interest in Harrow or in London. He said he went out with the staff and enjoyed doing this. He described playing ball games with staff as well as his TV viewing preferences. He said he also liked to listen to the radio in his room. He stated that he did not wish to go to day centre or look for employment. He said he had had a job when he lived in another part of England. He said he was happy in the company of the staff who spent a lot of time with him. The staff confirmed that they went out with the resident daily and assisted him in completing his daily personal routines. The resident’s daily routines and activity choices were detailed in the care file. The resident also spoke with his mother on the telephone for some time. He said that she visits him with another relative regularly bit he also wished to visit her if possible. He said he would ask the staff if he could visit his mother, as she wasn’t able to come to see him. Sophia Care Home Version 1.10 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 Residents have access to and are encouraged to attend regular health care appointment. Their medication is managed in a safe manner. EVIDENCE: The resident’s health care records had been required to be recorded in a more suitable format. This had now been achieved. The current resident had been registered with all the appropriate health care agencies. The manager stated that he had refused to go to the optician and dentist but did attend the chiropody service. He is registered with the local GP surgery. The psychiatrist monitors the resident’s medication. Records of all appointments were clearly documented. The manager has now amended the medication policy as required from the last inspection. The resident does not self medicate. Staff have now had training in using the monitored dosage system used in the home. Medication records were noted to be correct and up to date. Sophia Care Home Version 1.10 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents are encouraged to discuss any concerns they have with staff and are informed about how to make a complaint. There are policies in place for the protection of vulnerable adults. EVIDENCE: The resident informed the inspector that he had no concerns or complaints and that he knew to whom he could make a complaint. There was evidence in the records and in discussion with staff that the resident is listened to and consulted on all aspects of his care in the home. The manager had written a user-friendly complaints policy for residents to access. The adult protection policy had now been amended and a copy of Harrow’s Protection of Vulnerable Adults policy was in place. Staff have not yet attended training but the manager stated that this was in hand. Sophia Care Home Version 1.10 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The residents live in a homely, clean, well-kept and furnished environment. EVIDENCE: There has been no change to the premises since the last inspection. The building was noted to be clean, tidy and odour free. The manager informed the inspector that she has opened a day care centre in the unused lower part of the home. She said she has no clients as yet. The inspector was concerned and asked how this would be managed in the event of day care service users coming into the resident’s home in terms of toilet and catering facilities. The manager stated that there would be no problems. A letter was written to the manager requiring her give details of this change to the to the service to the CSCI was sent following the inspection. The. Sophia Care Home Version 1.10 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,34,35,36 Residents’ benefit from sufficient numbers of staff on duty that have had appropriate training and supervision to provide support to them. EVIDENCE: The home provides one to one support for the resident in all aspects of his daily living. Staff were observed to spend time with the resident but also giving him personal space. The resident stated that he enjoyed the company pf staff and going out with them. A training programme for 2005-06 was in place. The home uses an external training agency. Staff have attended medication training with the local pharmacist and risk assessments. They are due to have basic food hygiene, infection control and advanced care practice in the next few months. The staff member on duty confirmed that he had also had health and safety and fire safety training. He said he received regular supervision. The manager has now drawn up supervision contracts and has been recording all supervision sessions held with staff. Staff job descriptions have now been written. Person specifications and terms and conditions of employment were outstanding from the last inspection and will be required to be completed within the stated timescales. Sophia Care Home Version 1.10 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The residents live in a safe environment with appropriate and regular health and safety checks being carried out for their protection EVIDENCE: The certificates relating to the appliances used in the home had been inspected in February and many were still valid. The manager had had services for some appliances and the certificates were made available. The home has now carried out portable appliances testing including tests on the resident’s own equipment. There was a fire risk assessment in place. Drills and call bell tests were carried out and recorded. The home has carried out premises risk assessments as required from the last inspection. The accident reporting procedure has now been amended to include reference to the Regulation 37 and the reporting of significant events to the CSCI. The quality assurance system was not assessed on this occasion. It will be assessed at the next inspection. Sophia Care Home Version 1.10 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 Sophia Care Home x 3 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x x 3 3 3 Version 1.10 Page 17 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x Sophia Care Home Version 1.10 Page 18 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 31 Regulation 18(1)(a) Requirement Person specifications for the posts must be written (standard not assessed on this occasion, previous timescale 30.3.05) Terms and conditions for staff must be written and a copy given to staff on appointment. (previous timescaleof 30.3.05 not met) A quality assurance system policy must be developed and must include methods of monitoring the service through systems of reviews, surveys of stakeholders as well as service users and their relatives.(standard not assessed on this ocasion Timescale for action 30.9.05 2. 34 19(4)(5) 30.6.05 3. 39 24(1)(a)( b)(2)(3) )30.9.05 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 Good Practice Recommendations Sophia Care Home Version 1.10 Page 19 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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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