Inspection on 09/01/07 for Station Road 159a

This inspection was carried out on 9th 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station Road 159a 04/10/07

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Townley Road, 2-3

Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Station Road 159a 159a Station Road Hendon London NW4 4NH Lead Inspector Caroline Mitchell Key Unannounced Inspection 9th January 2007 11:45 Station Road 159a DS0000067008.V322022.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 159a DS0000067008.V322022.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 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station Road 159a Address 159a Station Road Hendon London NW4 4NH 020 8203 5029 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) www.norwood.org.uk Norwood Ravenswood Ltd T/A Norwood *** Post Vacant *** Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (8), Physical disability (2) Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two of the eight service users who have a learning disability and/or a mental disorder may also have a physical disability. One specified service user who is over 65 years of age may continue to be accommodated until such time as the service can no longer meet their needs or until they are discharged. 16/01/06 Date of last inspection Brief Description of the Service: The home is registered as a care home for eight adults who have a diagnosis of learning disability or mental disorder. Two specified service users may also have a physical disability. The home continues to care for one specified service user who is over sixty-five years of age. The home is run by Norwood, a Jewish charity operating services for adults and children with learning disabilities. The building opened in June 1997. 159A is a purpose built property located to the rear of a site that is shared with another, smaller home, also run by Norwood. There are five service users’ bedrooms on the first floor and three on the ground floor. There are toilet and bathroom facilities on both floors. The shared facilities of a lounge, dining room, kitchen and laundry are on the ground floor. There is a good sized garden. 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. The fees are from £1,730 to £961 for each placement per week, and service users are expected to pay separately for items such as hairdressing and clothes. 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 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis. It took around four hours to complete. It was undertaken by Inspector Caroline Mitchell, as part of the routine schedule of inspections for the home. The inspector was able to speak to six service users, most of whom do not communicate in conventional ways. The inspector met the acting manager and several staff members. This, along with written feedback from several service users and their families, written information provided by the registered person in the form of a pre-inspection questionnaire, a tour of the building, inspection of service users’ files, staff records, and general home records formed the basis of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Areas identified for improvement tended to be known to, and acknowledged by the acting manager. The care plan and risk assessments for the service user Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 6 who has recently returned from hospital need to be updated to reflect their increased health care needs, and the risks associated with MRSA. Where there are issues of treatment, consent and restraint for another service user, there is a need for a proper risk assessment to be undertaken as part of a multidisciplinary approach. The inspector gained the impression that the emphasis of the service has been changing over recent months. As several of the service users grow older, their health care needs are becoming more complex, and a challenge to the service. In order to help some of the service users to remain in their home there will need to be a very good level of health care planning, and solid support from relevant health care professionals, and the inspector felt that better communication needs to be developed in this area. Feedback from the acting manager indicates that, after some initial difficulty, a better understanding is gradually being developed between the home and health care staff and, in the best interests of the service users, the inspector hopes that this will continue. The staff training records need to be updated to show a true picture of the skills and the training needs within the team and, when the registered manager returns from maternity leave, a business plan needs to be completed and put in place for the service. 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 159a DS0000067008.V322022.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 159a DS0000067008.V322022.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&4 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 fully assessed before they move in and they are able to “test drive” the service so that they can be confident that their needs will be met. EVIDENCE: The inspector reviewed the written records of one service user, who moved into the home last year. The service user moved from living with their family into the home and is reported by the acting manager to have settled well. There was written evidence that the service user’s needs were been carefully assessed prior to the move and repeatedly reviewed throughout the settling in period. Station Road 159a DS0000067008.V322022.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users’ have individual plans that are of a good standard and reviewed in consultation with them, although changes in the needs and care arrangements for one service user need to be better documented. Service users are encouraged to make decisions that are relevant to them about their lives, and encouraged to be as independent as possible. EVIDENCE: One service users’ needs had changed considerably since being unwell, being admitted to hospital, and subsequently returning to the home. There was evidence that their health care needs were being prioritised, and that monitoring procedures and interventions were being practiced by staff to ensure any associated risks are minimised. It was evident that the staff were clear about the service user’s needs, and competent in their care tasks. However, the changes in the service user’s needs were not reflected in their profile, care plan or risk assessments, and requirements are made in respect of this. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. 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. Service users live active lives according to their wishes and abilities, are provided with opportunities for personal and social growth and leisure. They are supported to maintain links with family and community. Staff maintain service users’ privacy and dignity. The food provided is culturally appropriate and healthy, and offers variety and choice. EVIDENCE: It was evident that service users are provided with opportunities for leisure and learning, both in the home and in the community. The inspector noted that there were a number of people who provide support coming and going at the time of the inspection, these included a tutor who is working with one service user with the computer, another service user’s advocate and an art therapist. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 11 The service is part of the Norwood and Jewish communities and there are links between service users in different Norwood homes. Jewish celebrations are an integral part of the life of the home. Some service users participate in educational and day centre activities. These are individually geared to each person’s needs as documented in their care plans. The communal areas were very welcoming and well supplied with videos, DVDs, games, books and magazines for individuals to enjoy at their own leisure. One service user told the inspector that people have televisions in their own bedrooms. The acting manager explained that there is one service user who is quite reluctant to engage in activities, although there has been some progress, this is quite slow and can be source of worry to their familly. The inspector noted that there was plenty of fresh fruit available for the service users. Copies of rotational menus were provided to the inspector, and were noted to offer a good choice. The kitchen is kosher and Jewish meals are regularly offered. Service users’ needs are catered for and their preferences are sought and catered for. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care is provided in line with service users’ needs and preferences. A risk assessment regarding treatment, consent and restraint must be developed for one service user as part of a multi-disciplinary approach. EVIDENCE: The inspector reviewed the records of the personal and health care needs of two service users in some detail, and noted that the guidance for staff in relation to the personal care needs of these services users was very detailed. It included guidance regarding service users’ specific cultural needs and preferences, and the emphasis was very much on ensuring that they were encouraged to be as independent as possible, and their dignity maintained. As previously mentioned, one service users’ needs had changed considerably since being unwell recently, being admitted to hospital, and subsequently returning to the home. This service user returned to the home with increased medical/health needs. It was clear from the written records and from discussion with the acting manager that, when re-admitted, health care professionals provided support, to help deal with specific health care procedures and staff were shown how to provide appropriate care. The issue arose regarding what could reasonably be expected of the care staff, and what Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 13 should be considered nursing care tasks. The assistant manager told the inspector that this issues has now been resolved and district nurses are to attend daily to provide nursing care. At the previous inspection the registered person was required to ensure that a written agreement is drawn up setting out the arrangements for staff to administer insulin to service users. The acting manager told the inspector that this had been done and the inspector saw written evidence, along with certificates in individual staff files indicating that they had been appropriately trained. One service user was discussed, who has ongoing health issues, requiring medical intervention. Unfortunately this person has a fear of needles and has consequently, consistently refused to co-operate in simple medical procedures. This has led to staff using restraint in order to give injections. A risk assessment must be undertaken regarding this issue, as part of a multidisciplinary approach, and it is recommended that the acting manager write to the placing authority to seek their support in this process. Sadly, one service user had recently died quite suddenly, and the service users and staff were trying to come to terms with their loss. They were talking openly about what had happened, and supporting each other through this difficult time. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 14 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 can be confident that their concerns will be considered and addressed by formal and informal processes. The home uses the local adult protection procedure and service users are protected from abuse. EVIDENCE: The home’s complaints policy and procedure is appropriate and made more accessible to service users by the use of pictures. No complaints had been recorded in the home since the last inspection. Records reflect that staff have had adult protection training. Service user interests are also protected by Norwood’s lay advocate scheme. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 15 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 & 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 pleasant environment that is decorated and resourced to a high standard. The house was very clean and hygienic. EVIDENCE: The inspector was taken on a tour of the building. Communal areas and bedrooms were comfortably furnished, very pleasantly decorated and well supplied with recreational and personal items. The home is of a high standard and is well resourced. The acting manager told the inspector that the new flooring that has been provided throughout the reception area, lounge and office has been a real improvement. At the previous inspection the registered person was required to ensure that repairs were undertaken including a radiator, a lock keypad, a service user’s window, the kitchen floor seal and the hot water supply to two showers. The acting manager explained that all of these issues had now been addressed, and that the response times for repairs had improved. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 16 The home was very clean, and well equipped with proper hand washing facilities in all of the areas where this was needed. Infection control is maintained by safe working procedures, including a red bag system, and washing machines have sluice cycles. The inspector noted the careful way in which infection control procedures were being employed in caring for one service user, who has MRSA. Station Road 159a DS0000067008.V322022.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 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a competent staff team who are clear about their roles and responsibilities. Thorough pre-employment checks are undertaken prior to employing staff and training is provided that is relevant to the needs of the service users, although the records kept of training need to be kept up to date. EVIDENCE: The inspector saw the written records for all staff regarding the training that they have undertaken. These were noted to be well organised. However, the acting manager told the inspector that she had not been able to update the staff training records recently. This meant that they did not provide an up to date picture of the training that had actually been undertaken by staff and a requirement is made in respect of this. The inspector discussed the feedback from one service relative that highlighted concerns about staff consistency and their comprehension of English. The acting manager explained that there had been a period earlier in the year where a lot of bank staff were being used. She added that this was no longer such an issue, and the staff’s comprehension of English had improved. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 18 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are reasonable arrangements in place to manage the home in the absence of the manager, although there is a need for a business plan for the home. Service users are protected by a proactive approach to health and safety in the home. EVIDENCE: The registered manager has been on maternity leave and the registered person has put an acting-up arrangement in place in order to manage the home in the interim. The acting manager is supported by two assistant managers and says they are working well together as a team. At the previous inspection the registered person was required to ensure that fire drills are carried out regularly and to ensure that the COSHH cupboard is kept locked at all times. The inspector was able to confirm that these requirements have been addressed. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 19 At the previous inspection the registered person was required to ensure that a business plan is produced for the service. This has not been achieved and this requirement is restated as part of this report. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 20 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 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 X 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 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 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 2 X X 3 X 3 X X X 2 Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(2) Requirement The registered person must ensure that the care plan for one service user is updated to reflect the changes in his health care needs. The registered person must ensure that the risk assessments for one service user is updated to reflect the changes in his health care needs. The registered person must ensure that for one service user, where there are issues of treatment and restraint, these are clearly documented as part of their risk assessment, and these issues are monitored at each review as part of a multidisciplinary approach. The registered person must ensure that the record of staff training is updated and a copy be provided to the inspector. The registered person must ensure that a business plan is produced for the service. The previous timescales of 01/11/05 & 01/03/06 were not met. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 22 Timescale for action 01/02/07 2. YA9 13(4) 01/02/07 3. YA19 13 (7), (8) 01/02/07 4. YA35 5. YA43 17 Schedule 1 18 (1) (c) 25 (2) 01/03/07 01/05/07 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 YA19 Good Practice Recommendations It is recommended that the acting manager write to the placing authority to seek their support in undertaking a risk assessment regarding this issue of treatment and restraint. Station Road 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 23 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 159a DS0000067008.V322022.R01.S.doc Version 5.2 Page 24 - 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. 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