Inspection on 21/07/06 for Sophia Care Home

This inspection was carried out on 21st July 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sophia Care Home 30/10/07

Sophia Care Home 15/11/05

Sophia Care Home 12/05/05

Sophia Care Home 28/02/05

Sophia Care Home 21/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Sophia Care Home 236 Malvern Avenue South Harrow Middlesex HA2 9HE Lead Inspector Richard Adkin Key Unannounced Inspection 21st July 2006 08:00 Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sophia Care Home DS0000047917.V302700.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. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sophia Care Home Address 236 Malvern Avenue South Harrow Middlesex HA2 9HE 020 8426 8110 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) Ms Sophia Mirza Ms Sophia Mirza Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 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 people with learning disabilities, which is separate to the residential home. Fees range currently, depending on needs is £700-£850 per week for residents. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place on a midweek morning. The focus of the inspection was to look at the key national minimum standards. There had been no requirements or recommendations from the previous inspection to be addressed. The manager was most welcoming along with the one resident. Opportunity was afforded to make a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: The front door step need some work on as it presents as a tripping risk. The Protection of Vulnerable Adults (POVA) policy for the authority where the current resident originates must be available. Quality assurance needs to be developed at the care home. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 6 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. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 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 the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Prospective residents have opportunity to visit and test the care home. Service users are assured that the home will address their individual aspirations and needs. EVIDENCE: During the course of the previous week a prospective resident had made a preliminary visit to the care home, along with a family member and the care manager. The service user was looking at a number of care homes to reach a decision about a future placement. A comprehensive assessment is made of prospective residents that addresses their needs and the aspirations of that individual. The manager gave background information and provided the Inspector with a copy of the Policy of Emergency Admissions and the ‘Policy on Referral and Admissions’. The ‘referral and admission policy’ clearly details the necessary steps of the process. The eligibility criteria are explicit around the nature of presenting behaviours that cannot be worked with at the care home. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 9 There is a multi-disciplinary approach involving the potential resident, relatives and carers in identifying and establishing the therapeutic aims and objectives based upon a comprehensive assessment of needs. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported in making positive decisions and working towards independence realistically. EVIDENCE: Detailed daily records are kept for the one resident. These records capture food and drink intake, sleep patterns, activities, mood state, state of health, contact with family, personal hygiene, issues and concerns. There are several entries for each day. From observing the interaction between the manager and resident, discussion with the resident and looking at records, the nature of the needs are continually assessed and worked towards being met. Boundaries are worked on by care staff with the resident. The current resident is fully encouraged to follow his own interests and hobbies; he decides what he wears, where he goes, his likes and dislikes are documented. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 11 The manager and the resident advised the Inspector of the residents passion for riding on buses which is now undertaken independently. He likes to go to the pub on occasion and goes with a member of staff if he wishes. There are risk assessments in place on the resident’s file. Central to the ethos of running of the home is the focus of the home being person centred. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 12 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 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. Residents have the opportunity to engage in the local community and take part in appropriate activities. The rights of residents are fundamentally supported. Contact with family members is promoted. EVIDENCE: The resident currently at the care home has been offered day services and college, but has chosen not to take up these opportunities and pursue his own interests and hobbies. Some structured activities take place with the resident around numeracy and literacy and drawing. The resident has a number of activities that are important to him, he is fully supported by staff. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 13 There is a menu in place, but the resident contributes to the choice of food; he goes food shopping with staff members. The resident’s weight and diet is monitored because of health needs and he is supported and encouraged to maintain this. Meals are provided three times a day. Promoting the rights and choices made by the resident within an appropriate framework is evident in the practice observed within the care home. The resident was handled with dignity and respect by the manager of the care home. Contact is supported with family members and family members visit regularly and the resident stays with family members on occasion. The resident is in daily contact with a family member. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 14 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 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. Residents receive personal support in a manner that they prefer and require. The health needs of residents are addressed. EVIDENCE: The resident spoken to by the Inspector was positive about the support and encouragement that he receives around personal care. The home provides sensitive and flexible personal support to the resident and this was observed during the course of the inspection. The manager was aware and responsive to the needs of the resident. The resident recalled having a serious illness a few years previously. The practice nurse at the local GP practice provides the depixol injection fortnightly. Insulin injections take place four times a day which are supervised. The resident self-medicates and this is monitored by staff. The insulin medication is stored in the fridge. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 15 A record is kept of all health appointments, including opticians, dentist, chiropody, diabetes, GP and speciality services and the outcome of these appointments is recorded. The policy on medication for the care home was comprehensive and included a section on drug error and action to take on poisoning should it occur. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 16 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 the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents feel that their views are taken into account and are acted upon. Protection of Vulnerable Adults policies are in place, but must be comprehensive. EVIDENCE: The resident was adamant that he had no complaints about the care home and felt that if he did have concerns that this would be acted upon. The Complaints Policy is detailed and includes the principles and values of the care home. This includes a Service Users’ charter, i.e. a statement of rights. The complaints book was looked at, but there had been no complaints made. The Protection of Vulnerable Adults Policy for the care home was looked at by the Inspector. This is a clear policy that covers key areas around protecting vulnerable adults. The manager had undertaken POVA training and had put forward staff to undertake POVA training. There was a procedure for the London Borough of Harrow available, but a POVA procedure was needed for the authority where the current resident originated. This needs to be addressed and the procedure for contacting that authority addressed. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents live in a comfortable well maintained and homely environment. EVIDENCE: The home was clean and hygienic. It was comfortable, well furnished and homely. The outside of the care home was being professionally decorated during the course of the inspection. The resident showed the Inspector his bedroom which was spacious, well furnished and personalised. He was proud of his bedroom. The garden was well laid out and accessible. The step by the front door needs to be rectified as it has an overhanging lip that presents a tripping hazard. The manager said that she was reviewing access to the home to ensure that it was safe and addressed the physical needs of possible future residents. Sophia Care Home DS0000047917.V302700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are supported by a competent qualified staff and have a positive experience. EVIDENCE: The manager herself is experienced in the health and social care field. She has extensive experience in the area of substance misuse. She maintains her registration as an RMN, RGN and was a midwife for several years. There is only one resident currently; until the home expands its number the home will not utilise all of the staff that have been employed. They work at other care homes. The resident was positive about his experience of the care that he received from staff. Training is shared with other local homes in order to be cost effective. The care home’s ‘Policy on Recruitment’ was looked at by the Inspector and was satisfactory. This includes a statement of terms and conditions of employment. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 19 The personnel file was looked at for one staff member and included a current CRB check, application form, references, identifying data training information. Sophia Care Home DS0000047917.V302700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents benefit from a home that is well run. Quality assurance needs to be further developed. EVIDENCE: The policy and procedure documents of the care home reflect the manner in the way the care home is run; listening to the residents and supporting their aspirations is paramount. Fire checks and fire drills are happening regularly. In fact, fire checks are happening every three to four times per month. Recording of checks and drills were up to date. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 21 There is a Quality Assurance policy in place. Comments are received at reviews about the views of relatives that they have about the care home. The service could be further improved by developing quality review systems. There is a strong sense of the resident benefiting from the practice and values of the proprietor/manager. Sophia Care Home DS0000047917.V302700.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 X 2 X 3 3 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 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 3 X X 3 x Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 23 N/A 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 YA23 Regulation 13(6) Requirement POVa guidelines for the orginating authority of the resident must be in place. Timescale for action 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA24 YA39 Good Practice Recommendations The front step needs to be improved to prevent tripping. Quality assurance needs to be put into practice. Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 24 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 Sophia Care Home DS0000047917.V302700.R01.S.doc Version 5.2 Page 25 - 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!