Inspection on 30/10/07 for Sophia Care Home

This inspection was carried out on 30th October 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sophia Care Home 21/07/06

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 Judith Brindle Key Unannounced Inspection 30th October 2007 08:45 Sophia Care Home DS0000047917.V346319.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.V346319.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.V346319.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) sofcare@btinternet.com Ms Sophia Mirza Ms Sophia Mirza Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st July 2006 Brief Description of the Service: Sophia Care Home is care home registered to provide personal care and accommodation for five adults with a learning disability. The premises are in keeping with other houses in the residential area. The house is located in South Harrow, close to a variety of amenities, which include shops, restaurants and banks. Local public transport facilities include train and bus services. 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 kitchen and spacious communal lounge/dining area, located on the ground floor. There is a well maintained garden to the rear of the house, and parking for vehicles on the street at the front of the house. The home has accessible information about the care home and the service provided. The current range of fees is (depending on the residents needs) is £700-£850 per week. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day in October 2007. There were two vacancies at the time of the inspection. I was pleased to meet and spend sometime with the people living in the home. The registered manager was present during the inspection. Documentation inspected included, resident’s care plans, risk assessments, staff training records, and some policies and procedures. The inspection included a tour of the premises, and observation was a significant tool used in the inspection process. Assessment as to whether the requirement and the recommendations from the previous key inspection (21st July 2006) had been met also took place during the inspection. 27 National Minimum Standards for Adults, including Key Standards, were inspected during this inspection. Prior to this unannounced key inspection the registered manager/provider supplied the Commission for Social Care Inspection a completed Annual Quality Assurance Assessment (AQAA) document. This record includes required information from the owner and/or registered manager about the quality of the care home and their planned improvements for the service. There were areas of the AQAA (such as how the home has improved over the last year and plans for future improvements), which could have been completed more comprehensively. This was discussed with the manager. Reference to some aspects of this AQAA record is documented in this report. The inspector thanks the people living in the care home, staff and the manager for their assistance in the inspection process. What the service does well: The registered manager is experienced, competent and keen to put into place, systems and practice to continue to improve and develop the service. The care home has a very warm welcoming atmosphere, and homely, clean, bright environment. The home has an enclosed well maintained garden. Residents’ contact with relatives and others (as agreed by the residents) is fully supported and enabled by the care home. Residents spoke of the ways that they kept in touch with relatives and others. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 6 The care home follows an appropriate admission procedure, which fully involves residents and others, and ensures that the needs of each resident are fully documented. Staff have knowledge and understanding of ways to support residents to settle into the home and ensure that they receive a quality service. Resident’s care plan information is easily accessible by staff and generally comprehensive. Staff support residents to take part in a variety of preferred activities, which residents spoke of enjoying. Residents spoke of being happy living in the care home. 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. Sophia Care Home DS0000047917.V346319.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.V346319.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective residents to have the information that they need to make an informed choice about where to live, and to ensure that their needs are assessed prior to their admission to the care home. Prospective residents have the opportunity to visit the care home and to have a ‘settling in period’ prior to choosing to live in the home. EVIDENCE: The home has and accessible statement of purpose, and service user guide documents, which both include information about the service provided by the care home, and are up to date. The manager supplied the Commission for Social Care Inspection with a copy of this documentation following the unannounced inspection. These documents have been recently reviewed, but the copy of this recent statement of purpose document did not include all the required information recorded in an earlier record located in the service file at the Commission. The manager needs to ensure that all required information be accessible in the recently reviewed statement of purpose. The care home has an admission procedure, which includes an admission checklist of personal information, and procedures to be followed when a resident is admitted to the care home. These include registration with a GP, checking medication, and informing the resident of house rules and of health Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 9 and safety issues. There have been two people admitted to the home within the last year. There were two vacancies at the time of the inspection. The manager spoke of being in the process of assessing prospective residents. She informed me that following a referral from a Local Authority Care Manager, a comprehensive initial assessment is carried out by herself (and sometimes another staff member) prior to anyone being admitted to the care home. This assessment includes participation from the prospective resident, (relatives and significant others if agreed by the prospective resident) so as to ensure that the home can meet their needs. I was shown evidence of an initial assessment. This incorporated comprehensive information, which included assessment of the health, personal care, and social, religious and cultural needs, and some evidence of risk assessment of the person. Records and the manager confirmed that the funding Local Authorities also carry out comprehensive assessments. The manager spoke of the on going assessment process during the prospective resident’s visits to the home, and of visits by staff to their home. It was evident that the manager and staff were fully aware of the importance of well planned prospective residents introductory visits to the care home, and of close liaison with staff from the previous home, and with the Care Managers of the funding Local authority. I was informed that the transition process including visits to the home by prospective residents varies in regard to the individual needs of each resident. The manager spoke of all the resident’s views of a prospective resident being very important to ensure that there is compatibility amongst people living in the home. A resident spoke of visiting the home prior to their admission and of meeting the manager and other staff ‘several’ times. The manager spoke of visits to the home by relatives, which took place prior to all the resident’s being admitted to the home. The manager/provider confirmed that there is a month’s ‘settling’ in period for residents new to the home, and that regular review (six week and three month reviews, and more frequently if needed) of the resident’s needs taking place following their admission to the care home. Two residents who kindly spoke with me said that they had settled into the home, and were happy. Sophia Care Home DS0000047917.V346319.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all residents have a plan of care. Residents are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle, but risk assessment could be more comprehensively documented. EVIDENCE: All the residents have a plan of care. Each care plan was inspected. It was evident that the care plans are developed from the initial assessment. The manager spoke of the process of further developing the care plans from the process of ‘ongoing’ assessment during the transition period and once a resident moves into the care home. The care plans include a significant number of identified needs of each resident, such as health, personal care, social/employment, sexuality, communication, religious and behaviour needs. The care plans incorporate planned goals/objectives and action to be taken by staff and residents and others to achieve these goals. It is recorded in the Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 11 care plans that each resident participated in the development of their care plan, but there was no recorded evidence such as a signature from the resident that they agreed and understood their plan of care, and there should be documented agreed timescales for achievement of personal goals and for their review. It was evident that the care plans are a ‘working’ document for example achieved recorded goals are discontinued. There was evidence that the care plans were comprehensively reviewed regularly and that the resident, relatives and care managers had the opportunity to attend these review meetings. It was evident that the care plans were ‘working documents’, as identified needs were discontinued once that need had been met. Resident’s individual progress is documented every day. The content of these records was comprehensive, positive, and informative, and confirmed that staff have an understanding of the residents varied and complex needs. Staff were observed to interact with the residents in a sensitive and respectful manner during the inspection. It was evident that the care staff have a good understanding of the significant needs of the residents. Choice was offered to the residents frequently, and they were supported in making decisions. The manager spoke of residents having key workers It was evident from talking to residents and from records that residents are supported and encouraged to make decisions about their lives. People using the service spoke of choices that they made, and of support received to manage their finances (see Standard 23). The front door was locked during the inspection, which could be a form of restraint. This was discussed with the manager who spoke of the reasons for this. Each resident needs to have an agreed recorded risk assessments in regard to the front door being locked, and this needs to be included in the fire risk assessment, and advice sought from the local fire service if needed. Risk assessments include areas of potential risk, such as participation in household duties, and in regard to accessing the community facilities and amenities, but these could be further developed to ensure that all risks are assessed and are managed positively to help the people using the service to lead the life that they want. The risk assessments recorded evidence of having been recently reviewed. It should be evident that residents are aware of the risk assessments, for example they should (if able) have the opportunity to sign this risk assessment documentation. This was discussed with the manager. The care plans include a procedure and information about each resident that would be needed in the event that a person using the service might go ‘missing’. Sophia Care Home DS0000047917.V346319.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13 14, 15, 16, 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents living in the care home have the opportunity to take part in a variety of activities including those promoting personal development, and they are supported to maintain contact with family/significant others. The people using the service have their rights respected, and their responsibilities are recognised in their daily lives. Meals are varied and wholesome. EVIDENCE: Staff and records confirmed that the people living in the home have the opportunity to participate in a variety of preferred activities. Resident’s activity programmes were accessible and meet their individual needs, but some information recorded on one programme was not up to date. The recorded resident’s activity programmes should be up to date. Residents attend a day resource centre (that is run by the provider) for a number of days during some the week. Two residents spoke of enjoying the activities at the Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 13 centre, which included football and games of badminton, and of meeting friends and others at the centre. Other activities include sewing and knitting. Community based activities include regular walks to the local park, and local shopping. A resident went shopping with staff during the inspection. Staff spoke of recently arranging a birthday party for a resident. This resident said that he had enjoyed the party, and had received lots of presents. Birthday cards were displayed in the home, and the resident kindly showed me some of them. I spoke at length with two residents who told me about the variety of activities that they enjoyed, such as listening to music, and of the particular music bands that they liked. A resident spoke of enjoying bus rides, and told me that he had his own travel pass. The manager spoke of staff supporting residents to be as independent as possible, and of monitoring risks in regard to independent travel, by residents. She reported that she was supporting a resident to obtain a Local Authority travel pass, to enable the person to travel without paying on local public transport. Records and residents confirmed that residents participate in a variety of leisure pursuits during the weekends. The people using the service have the opportunity to develop and maintain personal and family relationships. Staff spoke of the varied contact that the residents have with their family. Some residents regularly visit family members. A resident has frequent stays at the home of a family member. Residents spoke of the contact that they had with family members. A resident had plans to visit a relative during the day of this inspection. A resident told me that they had recently gone on holiday with family members, and that they had had a ‘lovely time’. The visitor’s record book confirmed that there have been a number of visitors to the home. The home does not impose restrictions on visits (unless requested by the resident concerned). The home has a pay phone, which residents can use at anytime. Daily routines that promote independence, and choice are assessed and documented in the care plan. A resident spoke of keeping his ‘room tidy’. Staff spoke of the involvement of another resident in some household cleaning duties, which included participation in the laundering of their clothes, cooking, and ironing. I was informed that residents had been fully involved in the development and management of a vegetable patch in the garden. The people living in the home was observed to have unrestricted access to communal areas of the home, and their bedrooms. The residents moved freely within the home, and chose when to be alone or in company. Residents confirmed that they went to bed and got up when they wished. They had all chosen to have a ‘lie in’ at the time of the inspection. During the inspection, staff interacted with residents in a positive and respectful manner. Residents spoke of liking the staff and confirmed that the staff were supportive and helpful. It was evident from records, staff and from talking to residents that staff treated people using the service as individuals and that residents felt relaxed and at home. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 14 The home has a menu that was displayed in the kitchen. This included varied and wholesome meals. The manager reported that the menu was a general guide, and that residents on a daily basis generally chose meals. She recorded this on the menu during the inspection. Records confirmed that staff understood the importance of ‘health eating’, and guidance on eating healthily is accessible in the home. Dietary needs of individual residents are recorded in their plan of care. Staff spoke of there being a weekly shop with residents at the local supermarket, and that fresh produce and other items were bought locally on a regular basis. A resident went food shopping during the inspection. Residents said that they enjoyed the meals provided in the home, and a person using the service confirmed that he could choose what he wished to eat. He kindly told me what were his favourite meals. The manager said that residents eat out at a place of their choice at least once a week. Fresh fruit was accessible in the care home. A resident was observed to help himself to fruit during the inspection. Two residents were observed to have their breakfast during the inspection. This meal was unhurried and the residents spoke of choosing what they wanted to eat and said that they enjoyed their breakfast. A staff member was heard to ask a resident what he wished to eat for lunch. A variety of fresh, frozen, tinned and dried foods were stored in the kitchen. Meals eaten by people using the service need to be recorded. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 15 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): Standards 18, 19, 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s personal and healthcare needs are met. Systems are in place to ensure that medication is stored and administered safely, but it needs to be evident that staff have received appropriate medication training. EVIDENCE: The support that each resident requires with their personal care needs is documented in their individual plan of care. Residents have access to health care professionals to meet their health care needs. Appointments with the GP, community nurse, psychiatrist, dietician, optician, chiropodist and dentist were recorded. Records confirmed that residents receive hospital appointments and blood tests as required and needed. A resident spoke of having contact with healthcare professionals. Records confirmed that residents weight was closely monitored. The staff guidance in regard to meeting a resident’s medical needs following a seizure need to clearly record when the resident should be admitted to hospital. This was discussed with the manager. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 16 The home has a medication policy. Medication is stored securely. Medication administration records confirmed that there were no gaps in recording. A list of staff that administer medication including their signatures is recorded. The manager confirmed that staff receive medication training from a pharmacist. She also said that she ensures that staff receive ‘in house’ medication training during their induction, and that she ensures staff do not administer medication until judged as competent. The manager needs to ensure that she records the content of all medication training given to staff, particularly in regard to the number and variety of medication presently prescribed to the people using the service. It needs to be evident that staff who administer medication have a basic knowledge of how medicines are used and how to recognise and deal with problems in their use, and that staff are aware of the principles behind all aspects of the homes policy on medicines handling and records. Receipt and disposal of medication is recorded. Care plans inspected recorded evidence of assessment of medication needs of residents. The manager informed me that at the time of the inspection there are no ‘controlled’ drugs prescribed to people using the service. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 17 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): Standards 22, and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for ensuring that complaints are taken seriously and handled appropriately, and that residents are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints procedure, which is recorded in the service user guide and in the statement of purpose. The manager said that there have been no complaints, but several compliments. A resident spoke of talking to the manager if he had a ‘concern’/complaint. Residents said that they were happy living in the care home. The manager could seek ways of developing systems within the care home to demonstrate that residents are supported and encouraged to communicate any ‘concerns’ that they might have, and that these be documented. The care home has a protection of vulnerable adults procedure. This was not clear in regards to when to investigate a suspicion or allegation of abuse, and was amended by the manager during the inspection. The home has the safeguarding adults guidance from the placing authorities (this was a previous inspection requirement) and an old Harrow protection of vulnerable adults policy. The registered manager should obtain a copy of the up to date lead Local Authority safeguarding adults procedure. The registered manager confirmed that all staff receive abuse awareness training, and that this is also included in the staff induction programme. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 18 Residents have varying levels of support from staff to manage their own finances. Each has their financial needs assessed, which is recorded in their care plan. A person using the service spoke of ‘going to the Post Office’ to ‘get money’, and of spending some of their money on toiletries, and other items. Appropriate financial records of expenditure including receipts were available for inspection. The manager spoke of this documentation being audited by the resident’s Care Manager. It was evident that residents receive their entitled benefit allowances. The manager spoke of having recently spent sometime supporting a resident to obtain a significant amount of previously unclaimed benefits. This is commendable. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 19 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): Standards 24, 25 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely, clean and comfortable. The premises are suitable for the care home’s stated purpose. EVIDENCE: The care home is located close to the amenities and facilities of South Harrow. The house is in keeping with other houses in the vicinity. The care home is generally well maintained and clean. There could be some redecoration of some interior areas of the home to ‘brighten’ up the environment and the stair carpet could be cleaned. The sitting room carpet is stained in some areas and needs cleaning. There are furnishings of quality, and a large television, and a music system located in the sitting/dining room. A resident spoke of liking the home, and of it being a comfortable environment. There is an accessible, enclosed garden at the rear of the property. Vegetables are grown in an area of the garden. The manager spoke of the resident’s involvement in this. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 20 A resident kindly showed the inspector his bedroom. It was individually personalised, and contained pictures, photographs, a comfortable chair, music equipment, and a television. He spoke of being happy with his room. The home has an infection control policy/procedure. The premises are clean, and free from offensive odours. The care home has an infection control policy. Laundry facilities are located in an out building located in the rear garden, so away from food storage and food preparation areas. Records confirmed that staff receive infection control training. Staff were observed to wear protective clothing (i.e. disposable gloves) as and when needed. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 21 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): Standards 32,34, 35 and 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive some training to ensure that they are competent, and skilled to enable them to carry out their roles and responsibilities, but training (including staff induction) records and the frequency of one to one staff supervision could be improved. Arrangements are in place to ensure that residents are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: The staff rota was available for inspection. There are two care staff on duty during the day and a staff member carries out a ‘sleep in’ duty at night. The manager works most days in the home, and she spoke of the flexibility in the numbers of staff on duty, such as increasing numbers of staff on duty in response to resident’s changing needs, and that this could include having a ‘waking’ night staff on duty if needed. The hours of each staff shift were not recorded, but the manager documented this information onto the rota during the inspection. The names of the staff on duty and a photograph of them are displayed in the home. This was updated to show the correct information during the inspection. The manager reported that there were five permanent Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 22 staff (plus the registered manager) employed in the home and that there were several ‘bank’ staff, which work in the home as and when needed. Residents spoke positively about the staff, and records and people using the service confirmed that staff had a good understanding of the varied needs of the residents. The care home has a recruitment and selection policy/procedure. Staff personnel files inspected included required information including enhanced Criminal Record Bureau/ Protection of Vulnerable Adult checks (checks that confirm if a prospective staff member has a criminal record and whether they are banned from working with vulnerable adults). These staff personnel files could be reorganised to make the information more accessible. The manager reported that all staff receive a comprehensive induction programme when they commence working in the home. There were no records of staff induction available for inspection. There needs to be recorded evidence that all staff have received structured induction training, and foundation training. This should meet to Skills for Care standards, and include training in the principles of care, safe working practices, the organisation, care worker role, and the particular needs of the residents. The staff code of conduct was accessible in the care home. Records confirmed that staff had received statutory training including health and safety and food and hygiene training, but it was not clear from the records exactly what training staff had received and what training they needed including ‘refresher’ training. The manager should review the system of recording and planning staff training. I was informed by the manager that one staff member had completed NVQ (National Vocational Qualification level 2 in care and that two staff were in the process of achieving this qualification, and that another member of staff had plans to commence the care course. All care staff should complete an NVQ level 2 care qualification. The manager reported that staff receive regular staff supervision, at least three monthly. Staff should receive recorded supervision meetings at least six times a year from a senior staff member, in addition to regular contact on day to day practice. It was evident that the manager keeps records of 1-1 staff supervision. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 23 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): Standards 37,39 and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent and experienced to run the care home. Arrangements are in place to ensure that there are some effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home, but there needs to be an annual development plan of the service. So far as reasonably practicable the health, safety, and welfare of residents and staff is promoted and protected. EVIDENCE: The manager herself has several years experience supporting and working with residents who have learning disability. She confirmed that she is registered Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 24 RMN (Registered Mental Nurse), RGN (Registered General Nurse) and was a midwife for several years. It was evident that the manager works hard to meet inspection requirements and recommendations and is keen to continually improve the service provide by the care home. Records and the manager confirmed that she regularly updates her training and skills. The home has a Quality Assurance policy. The home has appropriate up to date policies and procedures. It is recommended that staff sign when they have read them. The home needs to complete an annual development plan of the service, to review the quality and reflect the aims and outcomes for people using the service. This year questionnaires about the service have been supplied to stakeholders, including residents and relatives/significant others. This feedback was positive (for example the service was described as excellent, by some people) about the quality of the service provided to those living in the home. Residents have the opportunity to attend regular resident meetings, and it was evident that review meetings give residents opportunity to express their views of the service. Required gas safety and electrical system checks are up to date. Required fire safety checks including fire drills, and fire equipment checks are carried out. The sitting room door was wedged open during the inspection, to enable easy access into the room by the residents. This needed to be included into the fire risk assessment, with procedures in place for ensuring that the door was closed at night. The manager recorded this need in this documentation during the inspection. The manager should consult with the local fire service to seek advice in regard to an appropriate safe mechanism being put in place to enable the door to be open during the day but will close if the fire alarm goes off. Hot water temperatures are monitored. Hot water tested by hand during the inspection was judged to be of a safe temperature. Fridge/freezer temperatures are monitored. There were several fridge temperatures recording –6 oc, which the manager agreed should have been recorded as 6 oc. She spoke of ensuring that staff have knowledge and understanding of the appropriate safe fridge temperatures. Household cleaning materials are stored securely. The home has a health and safety risk assessment. The employer’s liability insurance certificate was displayed and up to date. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 3 X Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4(1)(c) Requirement The manager needs to ensure that all required information be accessible in the recently reviewed statement of purpose. Each resident needs to have an agreed recorded risk assessments in regard to the front door being locked, and this needs to be included in the fire risk assessment, and advice sought from the local fire service if needed. Meals eaten by people using the service need to be recorded. The staff guidance in regard to meeting a resident’s medical needs following a seizure need to clearly record when the resident should be admitted to hospital. It needs to be evident that staff that administer medication have a basic knowledge of how medicines are used and how to recognise and deal with problems in their use, and that staff are aware of the principles behind all aspects of the homes policy on medicines handling and records. The sitting room carpet is DS0000047917.V346319.R01.S.doc Timescale for action 01/03/08 2 YA9 12(1) 13(8) 17(1)(a) 01/02/08 3 4 YA17 YA19 12(1) 13(4) 12(1) 13(1) 14(1) 13(2) 18(1)(c) 01/01/08 01/01/08 5 YA20 01/02/08 6 YA24 23(2) 01/02/08 Page 27 Sophia Care Home Version 5.2 7 YA35 18(2) 8 YA35 18(1) 9 YA39 24(1)(2) stained in some areas and needs cleaning. There needs to be recorded 01/03/08 evidence that all staff have received structured induction training. Staff need to have an individual 01/02/08 training plan and there needs to evidence that all staff have appropriate training to ensure that they can meet the needs (including their specialist and complex needs) of each person using the service. The home needs to complete an 01/02/08 annual development plan of the service, to review the quality and reflect the aims and outcomes for people using the service. 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 YA6 Good Practice Recommendations The residents should be given the opportunity to sign their care plans, and there should be documented agreed timescales for achievement of personal goals and for their review. • Risk assessment for people using the service could be further developed to ensure that there is recorded evidence that all risks are assessed and are managed positively to help the people using the service to lead the life that they want. • It should be evident that residents are aware of the risk assessments, for example they should (if able) have the opportunity to sign this risk assessment documentation. The recorded resident’s activity programmes should be up to date. The manager could seek ways of developing systems within the care home to demonstrate that residents are supported and encouraged to communicate any ‘concerns’ DS0000047917.V346319.R01.S.doc Version 5.2 Page 28 2 YA9 3 4 YA12 YA22 Sophia Care Home 5 6 7 YA24 YA34 YA35 8 9 10 YA36 YA39 YA42 11 YA42 that they might have, and that these be documented. There could be some redecoration of some areas of the home to ‘brighten’ up the environment and the stair carpet could be cleaned. The staff personnel files could be reorganised to make the information more accessible. • The induction should be to Skills for Care standards, and include induction training in the principles of care, safe working practices, the organisation, care worker role, and the particular needs of the residents. • All care staff should complete an NVQ level 2 care qualification. • The manager should review the system of recording and planning staff training. Staff should receive recorded supervision meetings at least six times a year from a senior staff member, in addition to regular contact on day to day practice. It is recommended that staff sign when they have read policies and procedures. The manager should consult with the local fire service to seek advice in regard to an appropriate safe mechanism being put in place to enable the door to be open during the day but will close if the fire alarm goes off. The manager should ensure that fridge temperatures are recorded correctly. Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sophia Care Home DS0000047917.V346319.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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