Inspection on 21/08/07 for Station Road 159

This inspection was carried out on 21st August 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station Road 159 26/01/07

Station Road 159 16/01/06

Station Road 159 21/07/05

Station Road 159 01/12/04

Station Road 159 19/05/04

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 Station Road 159 159 Station Road Hendon London NW4 4NH Lead Inspector Caroline Mitchell Key Unannounced Inspection 21st August 2007 11:00 Station Road 159 DS0000010532.V338645.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 Station Road 159 DS0000010532.V338645.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. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station Road 159 Address 159 Station Road Hendon London NW4 4NH 020 8203 5029 020 8203 5029 159stationrd@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood 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) Miss Clare Marie Leahy Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (5) Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A specific service user who is currently resident in the home and is over 65 years of age can reside in this home. The Commission of Social Care Inspection must be notified when she is discharged from the home. 26/01/07 Date of last inspection Brief Description of the Service: 159 Station Road is run by Norwood, a Jewish charity operating services for adults and children with learning disabilities. The building opened in June 1997. The home is a large detached property that has been adapted to accommodate 5 people. The kitchen/diner, the lounge and managers office are situated on the ground floor. 4 bedrooms and laundry are on the second floor and another bedroom on the third floor. There is an enclosed garden facility. The home has good access to local shops and the transport and other amenities of Hendon. The stated aim of the service is to provide high quality individualised residential care that will, together with day opportunity programmes enable people to maximise their educational and personal development. To develop a strong sense of religious and cultural identity, ensuring each person can self-determine their lifestyle and achieve their goals in life. Placements at the home cost between £650 to £950 for each person per week. Service users are expected to pay separately for some items and activities, such as eating out. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on an unannounced basis. The inspector met with the support worker on duty and also spoke with 1 of the people living in the home. 1 person wasn’t keen to talk and 3 others were having a day trip to Buckingham Palace. Upon her return from a meeting that she was attending, the registered manager aided the inspector for the latter part of the inspection. A tour of the premises took place and various records and policies were viewed including the written records for 3 of the people living in the home and of 2 of the staff. The medication records, complaints record, accidents and incidents and environmental risk assessments were also viewed. What the service does well: What has improved since the last inspection? What they could do better: Although the registered manager has recently returned from maternity leave it was evident that she was aware of the issues regarding record keeping and reviews that had arisen in her absence, and that she was taking action to address these issues. Since the last inspection monthly reviews had been introduced for residents and these had been beneficial in helping to monitor people’s quality of life and any health issues that they have. However, these had not been completed consistently for the past few months. Similarly, in recent months, staff one-to-one supervision had not been provided as Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 6 consistently as it should, and staff meetings had not taken place as often as is the ideal. 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. Station Road 159 DS0000010532.V338645.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 Station Road 159 DS0000010532.V338645.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): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Useful written information is available to prospective residents and their representatives. People’s needs are assessed prior to moving to the home and are kept under regular review. EVIDENCE: The inspector was provided with a copy of the most recent statement of purpose for the home and this included the aims and objectives and other useful information for anyone considering moving into the home. The inspector reviewed the written records one person who was most recently admitted to the home and found that there was a comprehensive needs assessment in place indicating that the home was made aware of the needs of the person prior to them being admitted. The home has a suitable admissions policy and procedure, which includes all prospective residents having assessments and undergoing trial, visits. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 have good, clear care plans. They can make decisions relating to their lives with assistance. Risk to residents is generally managed in an appropriate manner. EVIDENCE: The inspector reviewed the written records for 3 people living in the home. In each case, these included good quality care plans, along with risk assessments that were relevant to the needs, preferences and lifestyles of each person. Since the last inspection monthly reviews had been introduced for residents and these had been beneficial in helping to monitor people’s quality of life and any health issues that they have. However, these had not been completed consistently for the past few months. It was evident that the registered manager was aware of this and was addressing the issue, to ensure that monthly reviews were re-instated. A recommendation is made in relation to this. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 10 At the previous inspection the registered person was required to ensure that all care plans are regularly reviewed. At this inspection it was found that placement reviews had been undertaken. People were seen to have comprehensive risk assessments, which link through with their care plans. These had clear potential and actual risks described and how the risk could be minimised. The assessments were found to be regularly reviewed. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a range of appropriate activities within the home and local community. Residents have good relations with family and friends. People’s rights and responsibilities are recognised in the home and only 1 minor improvement was identified. Residents enjoy a good and healthy diet. EVIDENCE: People are treated as individuals and are encouraged to have their own interests. They benefit from a range of activities both on an individual and group basis. These include: bowling, sing a longs, fitness sessions, gardening, walks, shopping, swimming and holidays. Within the home people have access to DVD’s, games and reading material. Their rooms have televisions or music playing equipment. Most people attend day centres for educational and other activities. Although one person is getting older and is choosing to go out less often. Activities are tailored in line with people’s needs as indicated in their care plans. Many Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 12 activities take place in the local community. The home had the feel of an “active” home where people are seen as individuals with need for good social lives. On the day of inspection, 3 people were out with staff, having a day trip to Buckingham Palace. The celebration of Jewish traditions is an integral part of life in the home and staff assist people in this, for example in shopping for Shabbat. Most people have regular contact with their families. Some go to their family’s homes for visits and stays. Records reflect that proper thought is put into the support that people might need regarding relationships and sexual health. The resident who spoke to the inspector said they were “very happy”; well treated and respected by staff and this was borne out by observations during the inspection. The person was happy with the quality and quantity of food at the home. Menus are individualised and participate in menu planning, shopping and food preparation where able. Food stocks were seen to be ample at the time of the inspection with fresh produce in evidence. Advice has been sought from a dietician where appropriate for individuals’ needs. Food safety systems were in place such as temperatures of fridges and freezers being recorded. The inspector noted that where minor restrictions were in place, that these were supported by risk assessments, and devised in order to reduce risks posed to people’s wellbeing. A bathroom door was being locked to prevent access to a particular person, without supervision and this arrangement had not been reviewed recently. A recommendation is made in respect of this. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is provided in a manner appropriate to individuals needs. People have access to a range of health care services and their health care needs are taken seriously. The home has appropriate medicine procedures in place. EVIDENCE: People’s plans showed arrangements for providing personal care and clear guidance was in place for staff about encouraging people’s independence. A key worker system is in operation to increase the individuality of service users in respect of care giving. The staff member on duty and the manager were knowledgeable regarding people’s users needs. There was good documented access to a range of health professionals such as G.Ps, consultants in learning disability, Dentists, Opticians etc. Health needs are seen as an important part of a holistic approach to service users care and are followed through appropriately. Although there was evidence that the residents were being well cared for and their health care needs were being appropriately addressed with input from various health care services, the audit trails regarding their care were not as well-organised as they have been previously, and a recommendation is made in respect of this. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 14 The home operates a monitored dosage system of medicine administration. This was checked and found to be working well on the day of the inspection. All residents were prescribed some form of medication and none are assessed as able to self-administer. Clear records are in place of all medication that is received in the home, and of medication returned to the pharmacist. Staff have received appropriate training in the administration, uses and possible side effects of medication. Appropriate medication policies are in place and the medication was seen to be stored safely and securely. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted upon. Procedures for complaint resolution are appropriate. Policies and procedures are in place to minimise the risk to service users of abuse. People need support in managing their day t day finances and, although there are good practice procedures in place to protect people from financial abuse, this could be improved further by more regular audits of their financial records. EVIDENCE: The home was found to have suitable complaint policies and procedures in place. There had been no complaints made about the home since the last inspection. The home has a comprehensive policy and procedure in respect of safeguarding adults from abuse. The home also had a copy of the London Borough of Barnet’s policy. Staff have received training in what constitutes abuse and how to deal with and report any potential abuse situations. The written records of the 2 people that were reviewed by the inspector clearly set out the details of the support that they receive with their day-to-day finances. The registered manager explained that a policy is in place that safeguards resident’s best interests, allowing only named people access to resident’s money, and that detailed records are kept of people’s finances. Additionally, account balances are checked monthly. A volunteer had previously been undertaking independent audits of the accounts of resident are Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 16 spending. However, the last audit was over a year ago and it is recommended that this be addressed. Station Road 159 DS0000010532.V338645.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable and pleasant environment. The home is well equipped, well maintained, homely, clean, tidy and hygienic. EVIDENCE: The inspector toured the home with a senior staff member and found it to be very pleasant, well decorated and homely in appearance. The home was clean, tidy and warm with no evidence of safety hazards. There are sufficient toilets and bathrooms providing the choice of a shower or a bath. People’s rooms were found to be very much their own, being personalised with items such as photographs and ornaments. One person said they liked their room. There was no offensive odours to be found anywhere in the home. The equipment and furnishings were generally in good condition, although the sofa is nearing the end of its useful life, and a recommendation is made in respect of this. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by sufficient numbers of competent and qualified staff. The training of staff is given a good level of priority. The recruitment procedures are supportive and protective of service users. Due to a recent unsettled period in the management team, there is room for in improvement in the frequency of the formal supervision provided to staff. EVIDENCE: The inspector reviewed the written personnel records for 2 staff and found that records indicate that the home is following appropriate recruitment policies and practices. References and CRB checks are sought and maintained on people’s files along with proof of identity and right to work. The inspector saw the rota and this accurately reflected the numbers of staff on duty at the time of the inspection. There were sufficient staff in the team to provide 2 staff on duty at most times during the day, and the addition of the manager. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 19 Each staff member in the home had an individual training record. The manager said that training provided by Norwood was comprehensive and regularly available. Records showed that staff had completed training in various relevant areas such as POVA, food hygiene, epilepsy, first aid, diabetes awareness and COSSH. The home is well on track with most people having attained National Vocational Qualifications at level 2 or above. Staff supervision has been consistently good in the past. However, staff records indicated that although supervision was being provided over recent months, this has not been as regular as it should have been. The manager was aware of this and taking steps to address it and requirement is made in respect of this. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home appears to be well run, although it has gone through a bit of a rocky period recently, this is now being addressed with the return of the manager. The health and safety of service users are promoted and protected. EVIDENCE: The manager has recently returned from maternity leave and explained that the deputy manager had been covering the day-to-day management of the home, during this period, with the support of the staff team who all took on extra responsibilities. Unfortunately, the deputy manager had become ill recently, and some of the administrative systems and staff meetings and supervision had become less of a priority. It was evident that some of the paperwork was a little less organised and that meetings and staff supervision were less frequent during this period. However, it should be recognised that there was lots of evidence that the needs of the residents had been prioritised Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 21 and that the remaining team members had successfully maintained the standard of their care. In addition, the inspector noted that residents meetings took place reasonably regularly throughout this period so that residents still had an opportunity to share their views. The health, safety and welfare of service users were seen to be promoted and protected in a number of ways. Certificates of safety were seen for gas, electrical installation and appliances and for water safety. Fire equipment had been checked and regular alarm tests and drills had been carried out. Risk assessments for the building were available including COSSH assessments. The environment was well maintained. As indicated throughout the report, staff had received training in a number of safety related areas such as food hygiene. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 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 2 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 2 3 X X 3 X Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 23 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. YA36 Standard Regulation 18 (2) Requirement The registered person must ensure that all staff are provided with formal one-to-one supervision at least 6 times per year. Timescale for action 06/10/07 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 It is recommended that the monthly review format be reintroduced for all residents. 2. YA16 It is recommended that the risk assessment in relation to residents having access to 1 of the bathrooms be reviewed. 3. YA19 It is recommended that the manager continue to focus on improvement of the organisation of the residents’ written records, particularly in the area of health care needs and Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 24 treatment. 4. YA23 It is recommended that representatives of Norwood arrange to audit the written records of resident’s financial transactions. 5. 6. YA24 It is recommended that the sofa in the lounge be replaced. YA38 It is recommended that the manager continue to ensure that staff meetings take place on a regular basis. Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 25 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 Station Road 159 DS0000010532.V338645.R01.S.doc Version 5.2 Page 26 - 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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