Inspection on 26/01/07 for Station Road 159

This inspection was carried out on 26th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station Road 159 21/08/07

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 Stephen Boyd Key Unannounced Inspection 26 January 2007 11:50 Station Road 159 DS0000010532.V323096.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.V323096.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.V323096.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.V323096.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. 16th January 2006 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. 159 is a large detached property that has been adapted to accommodate five service users. The kitchen/diner, the lounge and managers office are situated on the ground floor. Four service user 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. A copy of this report can be requested directly from the home or accessed via the CSCI website (web address on page two of this report) Station Road 159 DS0000010532.V323096.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 in one day in January 2007. This was the first inspection of 159 Station Road as a separately registered care home; it was previously part of a larger registered care home occupying two separate buildings in close proximity at 159 and 159a station road. The inspector met with the two support workers on duty and also spoke with all four service users at home during the course of the inspection. A tour of the premises took place and various records and policies were viewed. What the service does well: What has improved since the last inspection? What they could do better: Two requirements from the previous inspection still needed to be addressed in relation to ensuring all care plans are regularly reviewed and having a business plan available for the home. This inspection highlighted two further requirements. These are that staff records such as Criminal records bureau checks and references need to be available to inspectors so that a judgement can be formed as to the suitability of recruitment policies and practices within the home. Also, there was no access to any documents relating to the homes quality assurance processes, such as service user surveys and action plans based on quality auditing. Station Road 159 DS0000010532.V323096.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. The summary of this inspection report can be made available in other formats on request. Station Road 159 DS0000010532.V323096.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.V323096.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): 2 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to moving to the home and are kept under regular review. EVIDENCE: No new service users have been admitted to the home in the last two years. Service users at the home had undergone comprehensive needs assessments. The home has a suitable admissions policy and procedure which includes all prospective service users having assessments and undergoing trial visits. Station Road 159 DS0000010532.V323096.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 and 9 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users have good care plans. They can make decisions relating to their lives with assistance. Risk to service users is managed in an appropriate manner. EVIDENCE: Service users sampled were found to have comprehensive, holistic care plans. These had clear aims and how these could be facilitated. One service user’s plan had not had a review written since June 2006 and this needed to be rectified. There were good daily records written to complement the care plans, indicating what care had been given on a daily basis. Each service user had a personal profile written which gave details of their history. Observations and discussions with service users and staff during the inspection indicated that service users are very involved in decision making. Staff were seen to communicate well with service users, asking questions and explaining day-to-day issues. In discussion with the inspector, service users said they Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 10 could decide on what to wear, what to eat, where to sit and what time to get up and go to bed. Service user meetings take place in which they can contribute to the overall operation of the home. Service users were positive about he home and the care they receive from staff. Service users were seen to have comprehensive risk assessments. 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.V323096.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 and 17 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users benefit from a range of appropriate activities within the home and local community. Service users have good relations with family and friends. The rights and responsibilities of service users are recognised in the home. Service users enjoy a good and healthy diet. EVIDENCE: Service users 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 service users have ample access to DVD’s, games and reading material. Service users rooms had televisions or music playing equipment. Service users attend day centres for educational and other activities. Activities are individually tailored in line with service users needs as indicated in their plans of care. Many activities take place in the local community. The home had the feel of an “active” home Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 12 where service users are very much seen as individuals with need for social interaction. The celebration of Jewish traditions are an integral part of life in the home and staff assist service users for example in shopping for Shabbat. Most service users have regular contact with family. Some go to their family’s homes for visits and stays. On the day of inspection, one service user was having lunch out with a relative. Service users spoken with said they were well treated and respected by staff and this was borne out by observations during the inspection. Service users have responsibilities in the running of the home such as helping to make lunch and cleaning up, however, these tasks are with a view to increasing participation and independence and not as a substitute for staff levels which are appropriate. Service users spoken with during the inspection were happy with the quality and quantity of food at the home. Menus are individualised and service users 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. Food safety systems were in place such as temperatures of fridges and freezers being recorded. Station Road 159 DS0000010532.V323096.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 and 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. Service users have their health needs met. The home has appropriate medicine procedures in place. EVIDENCE: Service user care plans showed arrangements for providing personal care. Service users spoken with indicated this was given in an appropriate manner taking into account individual needs. A keyworker system is in operation to increase the individuality of service users in respect of care giving. Staff were knowledgeable regarding service users needs. Service users were seen to have 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. 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 Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 14 service users were on some form of medication and none are assessed as able to self-administer. All 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.V323096.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 and 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. 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. No service users raised any concerns during the inspection and felt if they had any these would be considered and acted upon. A total of nine comment cards were received prior to the inspection. Four from service users, one from a relative and four from health professionals. None of these had any negative comments. One health professional stated, “The staff are clearly motivated to work with their clients” 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. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This Judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and pleasant environment. The home is clean, tidy and hygienic. EVIDENCE: 150 Station road was found to be well-decorated and homely in appearance. Since the previous inspection repairs had been made to the main shower, a radiator in one service users room and windows in another service users room. A keypad lock had been fitted to the front door. New flooring has replaced carpeting in a number of rooms. The home was clean, tidy and warm with no evidence of safety hazards. Rooms were found to be personalised with items such as photographs and ornaments. Service users said they liked their rooms. There was no offensive odours to be found anywhere in the home. One area that needed to be remedied was replacing some tiles on the side of a bath in the bathroom upstairs. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 17 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 and 35 Quality in this outcome area is adequate. This Judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. The training of staff is given a good level of priority. The inspector could not determine through records not being available whether recruitment procedures are supportive and protective of service users. EVIDENCE: Each staff member in the home had an individual training record. Staff spoken with said that training provided by Norwood was comprehensive and regularly available. Records showed that staff had completed training in various areas such as POVA, Food hygiene, Epilepsy, First aid, Diabetes awareness and COSSH. A training plan was seen to be in place for 2007. All except one staff member at the home had completed National Vocational Qualifications at level two or above. The other member of staff was currently undertaking an NVQ. The inspector interviewed two members of staff and found them knowledgeable and competent. Staff felt supported by the manager and deputy and said regular staff meetings and supervision take place. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 18 The inspector could not fully determine whether the homes’ recruitment policies and practices were supportive and protective of service users as the senior member of staff on duty did not have access to information such as Criminal records bureau checks, staff references, application forms, medical declarations and identity details. Staff did say they had undergone all these processes prior to employment. A requirement to have such information available to inspectors is given at the end of the report. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 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. The health and safety of service users are promoted and protected. The inspector could not determine whether service users views are taken into account in formal quality review processes due to non-availability of records. EVIDENCE: The manager of the home Miss Clare Leahy was on leave at the time of the inspection. From discussions with service users and staff it was apparent she is well liked and respected. Her support and leadership was clearly valued. The evidence during the inspection largely points to a well run home as seen by the majority of quality judgements. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 20 The senior staff member on the day of the inspection was not able to access information on quality assurance processes within the home. Therefore a full judgement on this standard was not possible as self-monitoring, auditing and action plans could not be assessed. Service users certainly felt their views were important and they were involved in regular meetings. As indicated earlier in the report comment cards received by the CSCI were favourable. 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. As indicated throughout the report, staff had received training in a number of safety related areas such as food hygiene. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 21 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 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 3 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 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 2 Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2) Requirement The registered person must ensure that all care plans are regularly reviewed. This is a repeat requirement. Previous timescale of 1/3/06 not fully met. Timescale for action 28/02/07 2. YA34 17 (3) (b) 3. YA39 24 4. YA43 25 (2) The registered person must 28/02/07 ensure that staff records which indicate whether the home is following appropriate recruitment policies and practices are available for inspection by the CSCI. The registered person must 31/03/07 ensure a system of quality monitoring, audit and action planning is in place and available for inspection by the CSCI. The registered person must 31/03/07 ensure that a business plan is produced for the service. Previous timescale of 01/11/05 not met. Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Station Road 159 DS0000010532.V323096.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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.V323096.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!