Inspection on 05/12/08 for Sudbury Care Homes 67 Sudbury Avenue

This inspection was carried out on 5th December 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sudbury Care Homes 67 Sudbury... 28/11/06

Sudbury Care Homes 67 Sudbury... 23/01/06

Sudbury Care Homes 67 Sudbury... 13/05/05

Sudbury Care Homes 67 Sudbury... 24/01/05

Sudbury Care Homes 67 Sudbury... 07/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Sudbury Care Homes 67 Sudbury Avenue 67 Sudbury Avenue Wembley Middlesex HA0 3AW     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Andreas Schwarz     Date: 0 5 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Sudbury Care Homes 67 Sudbury Avenue 67 Sudbury Avenue Wembley Middlesex HA0 3AW 02089225138 02089227873 sudburyhomes@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Danalutchmee Tyahooa Name of registered manager (if applicable) Mrs Danalutchmee Tyahooa Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 5 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Date of last inspection Brief description of the care home The home is owned and run by Mrs Tyahooa. It is a three storey-terraced house in a residential area of North Wembley. The company is trading under the name of Sudbury Care Homes Ltd and has a second home in Stanmore. The home is situated about 5 minutes walk from North Wembley train station and East Lane where buses are available to Wembley and to Harrow. There is parking for about two cars in front of the home and there is additional parking on the road. The home also states in its statement of purpose that it provides its own transport for people using the service to go shopping and attend day centres. There is a large park opposite the home. There Care Homes for Adults (18-65 years) Page 4 of 29 care home 5 Over 65 0 5 Brief description of the care home are some shopping facilities on East lane and more extensive shopping facilities and local amenities are available in Wembley or Harrow. The home is registered for five service users with learning disabilities and has currently no vacancy. Accommodation is in single bedrooms. Charges and fees can be obtained from the registered manager on request. Care Homes for Adults (18-65 years) Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced key inspection took place in November and December 2008 and lasted seven hours. We spoke to two people using the service, the registered manager, the deputy manager and two senior member of staff. We had a tour of the premise and assessed two care plans, two staffing files and other records. The deputy manager Mr Tyahooa was available throughout both days of this inspection. Four service users surveys and six staff surveys have been returned to us prior to this inspection. Information of these surveys has been included in this report. The home forwarded a detailed Annual Quality Assurance Assessment (AQAA) to us, evidence from the AQAA has been used throughout this report. We would like to thank residents, registered manager, deputy manager and support staff for the help and openness during this inspection. Care Homes for Adults (18-65 years) Page 6 of 29 Care Homes for Adults (18-65 years) Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 29 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and health care 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New prospective service users receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet the needs of new prospective residents. Evidence: This is what you told us in your Anual Quality Assurance Assessment: - We conduct a comprehensive assessment of prospective clients prior to admission. We organize trial visits for new prospective service users to test drive the home. - We provide brochures, a detailed service users guide and statement of purpose. - We involve the client, family and advocacy in the admission process. - We review the placement after six weeks involving significant others such as family, social worker, advocate, key worker and the person. This is what we found during this inspection: Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: The home has reviewed the service users guide and statement of purpose together with the people using the service in October 2008. Both documents are compliant with National Minimum Standards and provide information about the care and support provided by the home. The statement of purpose and service users guide is available in pictorial form. We viewed two care plan folders during this key inspection and all folders contained a copy of the service users guide, statement of purpose and most recent inspection report. One resident told us that he knows about the service users guide and staff discussed the document with him. The home had one new admission since the last key inspection. The registered manager has undertaken a very detailed needs assessment, which involved the person, the previous placement and the persons advocate. The person visited the home five times prior to him accepting the placement. The visits constituted of lunch, evening, weekend and overnight visits. Visits were documented in detail and information was included in the needs assessment. Information from the needs assessment forms part of the persons care plan. Care Homes for Adults (18-65 years) Page 11 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are of very good standard and service users involvement is evident throughout all care plans. Residents can choose where to go, what to eat and evidence of this was observed during this inspection. The home has detailed risk assessments in place and service users are involved in the review process. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - All residents have their own individual care plan, with clearly stated goals and choices. - Care plans are reviewed regularly together with the clients and any significant others if the service user is happy to invite them. - Care plans are person centered and we ensure that clients aims, ambitions and desires are fulfilled. - Risk assessments are reviewed regularly and clients are involved in the process. This is what people using the service told us: Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: We have received four completed service users surveys. All told us that people using the service always make decisions of what they want to do. One person told us that he has seen his care plan and choose pictures to be included in his person centered plan. This is what we found during this inspection: We looked at two care plans during this inspection. Both care plans were of excellent standard. Care plans have been reviewed during the past six months. Residents, advocates, family members, key worker and social worker are involved in the review process. Each care plan has clear achievable short, mid and long term goals. Pictures, photographs and symbols are used throughout the care planning process. Both people using the service have attended a placement review, arranged by the placement officer of the placing authority. Staff told us that they started to meet monthly with each clients to discuss goals and any other issue relevant to the person. Each person has a seperate person centered folder, which is using pictures and symbols and very little words. Residents told us that they have chosen the pictures together with their key workers. The home addresses issues relevant to people using the service, i.e. personal care, activities, holidays, physical health and nutrition, medication, cultural and spiritual needs, etc. People using the service told us that they can make decisions of where to go, what to do, etc. Staff were observed supporting residents to go to a local shop to purchase some personal items. People using the service have advocacy involved if they wish or if there is a need. The manager told us that the home is currently looking into involving an advocate closer to the home. We looked at finances, income and expenditures were clearly recorded. Benefits are paid into a personal account, which can be accessed by the person. We viewed a wide range of very detailed risk assessments. Risk assessments are reviewed during care plan review meetings or if peoples needs are changing. People using the service are involved in the review process and one person told us that he should not do a certain activity due to health risks. The manager told us that risk assessments are done prior to admission, records viewed confirmed this. We viewed pen pictures in service users files and a missing person procedure is in place. Care Homes for Adults (18-65 years) Page 13 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is supporting residents to live a full, culturally appropriate and stimulating life. Residents can choose where to go, what to do and what to eat and are involved in the planning of activities. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - Residents attend personal development classes offered by local colleges. - The home supports people using the service to maintain relationships. Residents access the local and wider community for leisure activities. - Residents have attended sexual awareness classes, which enables them to understand boundaries and form friendships. Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: This is what people using the service told us: I take part in preparing my own timetable for activities. I have recently joined a dance and drama class, which I enjoy very much. During the weekend I go swimming, play golf, go to the library, cinema or bowling. This is what we found during this inspection: All residents living at the home attend daycentres or colleges. The home is providing transport and has a driver employed to assist residents attending daycentres and colleges. One service users has a part time job at a local charity shop he told us that he loves the job and is planning to do extra days. Residents attend computer classes in the evening. During the day of this inspection one resident was at home and we observed planned activities such as drawing, doing puzzle, etc. People using the service told us that they go regularly to the pub and have occasional Sunday lunches in a restaurant. Records viewed confirmed this. All residents are on the electoral register and are encouraged to vote. Adequate staffing numbers support residents during evenings and weekends. The staff team represents the cultural background of residents. Residents are able to go to their chosen place of worship. The manager told us that one of the people started to show interest in attending church and plans are made to support the person around this. The home has an excellent sexuality policy in place, which has been updated and is available in pictorial form. The policy addresses cultural issues as well as personal issues. Residents attend social clubs and go to discos to form and maintain relationships. People using the service regularly access the community. One person told us that he has a girlfriend, which he meets regularly. People using the service regularly visit or are visited by relatives. All but one person have their own key and residents rooms are locked if they are not at the home. If people do not or are not able having a key clear records of this are on file. We observed staff interacting with people in a professional and respectful manner. Residents informed us that staff are very friendly and listen to their problems. One person told us that he is very happy in his home. We observed residents moving around freely. Residents have allocated tasks during meal times and are responsible for the upkeep of their rooms. We observed people using the service clearing the table and helping staff with the washing up. One person told us that he likes to help staff doing the cooking. The home has clear guidelines about smoking, alcohol and drugs in place. Care Homes for Adults (18-65 years) Page 15 of 29 Evidence: The home is providing a varied and healthy diet. People using the service health care needs are taken into account and low fat options are recorded on menus. Residents meet weekly to discuss the new menu, this is done with the use of pictures and all residents can choose according to their likes and dislikes. Cultural meals are provided and residents confirmed of being happy with the meals provided at the home.People told us that they are involved in food shopping and preparation of meals. The home displays the daily menu in the dinning room and a clock informs residents of the times when meals are served. People using the service told us that they enjoy the food and that they are able to choose a different meal if they are not happy with the meal provided by the home. The home is providing cultural meals, but residents told us that they prefer English meals. All meals are home cooked. We observed people using the service accessing the kitchen and helping themselves to snacks and or drinks. Care Homes for Adults (18-65 years) Page 16 of 29 Personal and health care support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users health and personal care is managed very well. People using the service are encouraged to be as self-managing as possible. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - Staff receive regular medication training. - The manager and pharmacist is regularly auditing medication. - Staff support people using the service to attend health care appointments. - We have a detailed medication policy in place. This is what people using the service told us: I like the staff very much, they treat me well and help me if I need help. This is what we found during this inspection: We viewed detailed personal care guidelines in both care plan folders assessed. The Care Homes for Adults (18-65 years) Page 17 of 29 Evidence: guidelines are reviewed together with the person every six-month. Daily records show that people using the service can get up or go to bed when they choose. Residents have been dressed appropriately for their gender and the season and informed us that they have chosen and purchased their own clothes. If new clothes are purchased an inventory list is up dated. New staff will meet the people in their home prior they are been offered a post. The home has good links with Brent and Harrow Learning Disabilities Teams and specialist services are provided if needed. We viewed detailed records of visits and appointments of health care professionals. People using the service told us that they have a key worker, whom they meet regularly to discuss care plans and any other issues. Records of these meetings have been viewed. All people using the service are registered with their own General Practitioner. Regular visits to opticians, dentists are arranged and people using the service are supported by staff to access these. Outcomes of these visits are clearly recorded and any follow ups are discussed within team meetings and are recorded in the communication book.We viewed in care plans clear behavior intervention plans and Epilepsy guidance. Any accidents and incidents are clearly recorded. Staff told us that incidences are discussed in team meetings and risk assessments or intervention plans are put into place if necessary. The home is regularly monitoring peoples weight and dietitians are involved if their are issues with obesity or any other health related issues. We viewed clear evidence of the home following up health issues and supporting the person to become better. The home has a detailed medication policy in place, which is compliant with National Minimum Standards. The policy was reviewed in September 2008 We assessed two medication records both were of good standard and had no gaps. Clients medication is reviewed every six month by a health care professional. None of the people living at the home self medicate. People using the service requiring PRN have clear guidance in place for staff to follow. The home is using Boots Monitored Dosage System. We sampled two staffing records, certificates of recently attended medication training were in place. A list displayed in the office documented that all staff have received medication training. All staff has attended formal medication training and a signatory list of staff being competent is in place. Care Homes for Adults (18-65 years) Page 18 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and selfharm. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - We provide Safeguarding Adults training for all staff. - We provide a complaints policy in a user friendly format. - All staff are appropriately vetted and checked before employment is offered. - We hold regular meetings enabling people using the service to discuss any issues. This is what people using the service told us: I have a tape, which helps me to understand complaints better. I attend regular meetings where I can say what I feel and want. I would talk to my key worker if I am unhappy. This is what we found during this inspection: The home has a complaints policy in place, the policy is easily accessible for people Care Homes for Adults (18-65 years) Page 19 of 29 Evidence: using the service, staff and visitors. The policy is available on a tape, residents told us that they have seen and used the tape. People using the service told us that they would go to the manager or their key worker if they had any complaints. Complaints have been documented and dealt with appropriately. The home is recording complaints in the complaints book and on a separate form this allows to record more detail of the complaint and the actions undertaken to resolve the complaint. The home has received five complaints since the last inspection, the complaints were about broken draws, cups being replaced,ripped table cloths, etc. All complaints have been dealt with satisfactory and people spoken to are happy with the outcome of the complaint. The home has a Safeguarding Adults policy in place. Safeguarding Adults guidelines from hosting as well as funding borough are available. All staff attended Safeguarding Adults training. The home did not make any Safeguarding Adults related allegations since the last inspection. The home has a Whistle Blowing, Violence and Aggression and separate Abuse policy in place. Staff spoken to demonstrated very good understanding of how to report and record allegations of abuse. A seperate Safeguarding training folder is in place. Care Homes for Adults (18-65 years) Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using a nicely decorated and homely environment. Health and Safety is taken very serious and people using the service are protected by detailed risk assessments. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - The home has a homely feel and clients possessions and photos are on display. - The home has a maintenance and renewal program to ensure furniture are replaced if they are worn. - Residents are actively involved in the redecoration of their home. This is what people using the service told us: I really like my room and staff helped to decorate it. I choose this room and staff helped me decorating. This is what we found during this inspection: Since the last inspection the home has redecorated the lounge, hallway and dinning area. Four of the residents room have been redecorated and laminated flooring was Care Homes for Adults (18-65 years) Page 21 of 29 Evidence: laid. The office has moved to the first floor. This was due to a service user choosing the previous office as his bedroom. The home has a maintenance person employed. One of the people using showed me his room, he told me that he decorated the room by himself. The home is overall very comfortable and nicely decorated. The manager told us that the home is planning to redecorate the hallway in the future. The home is undertaking safety checks every two months and maintenance checks monthly. Information obtained during this checks is included in the annual development plan. The home was clean and free of any odours. People using the service and staff are responsible for the cleanliness of the home. Residents told us that they have responsibilities around the upkeep of the home. Cleaning material is safely stored and locked away. A detailed risk assessment for the safe use of cleaning material is in place. We viewed evidence of staff attending Health and Safety and risk assessment training. The laundry area is located outside of the home. Residents told us that they dont mind having to go out to do their washing. Care Homes for Adults (18-65 years) Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service benefit from a diverse, experienced and skilled staff team. Appropriate recruitment policies and procedures protect people using the service from unsuitable staff. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - We have a strong staff team with a clear structure and purpose. - We involve people using the service actively in the recruitment process. - We hold regular staff and residents meetings. This is what people using the service told us: I like my key worker and she helps me to do things. This is what staff told us: I love my job and the clients. I had an interview and had to provide documents for a police check. The home is providing me with regular training. We have a very good Care Homes for Adults (18-65 years) Page 23 of 29 Evidence: staff team. This is what we found during this inspection: The home employs ten staff, five staff have achieved their National Vocational Qualification in Care and four staff are working towards achieving their qualification. The home does not employ staff under the age of 18. We observed staff supporting people using the service and noted staff to be patient and having good listening skills. During the day of this inspection the sampled rota had two care staff and the manager on duty during the morning and during the afternoon. One member of staff is on duty during the night. The home has a recruitment policy in place, all new staff are issued with the General Social Care Councils Code of Conduct, induction pack and staff handbook. We viewed two staffing files, all necessary documents such as two references, contract, proof of the right to work in the United Kingdom and Criminal Records Bureau checks were in place. People using the service interview new staff, this is recorded by one of the panel members. All staff have a detailed training and development plan, which is updated regularly. The home is providing mandatory training; such as manual handling, First Aid, Fire Safety; etc. regular refreshers for existing staff is provided. The home is offering specialist training if needs of people using the service are changing. The deputy manager is currently undertaken his assessor qualifications and will act as a work based assessor for the home. The home has very detailed training records in place and staff confirmed of having received a range of training such as Health and Safety, Loss and Bereavement, Equality and Diversity, etc. Staff told us that they have received regular supervisions and records showed that over the period of one year six planned supervisions and one appraisal was provided. This evidence was found in both files assessed during this inspection. In addition to this staff meet regularly for meetings to discuss client and any issues relating to the home. Care Homes for Adults (18-65 years) Page 24 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager is skilled and qualified to manage the home. People using the service are actively involved and consulted in the running of the home. Clients Health and Safety is not compromised and safe working practices are in place. Evidence: This is what you told us in your Annual Quality Assurance Assessment: - Management and senior staff have undergone role specific training to improve the outcomes for people using the service. - Quality assurance and annual development plans are in place to support the development and improvement of the service. People using the service are involved in the running of the home (Recruitment, cleaning, activity charts, decoration, maintenance, etc.) This is what people using the service told us: The manager is around to help me. Care Homes for Adults (18-65 years) Page 25 of 29 Evidence: This is what we found during this inspection: The registered manager/provider Mrs Tyahooa has been working at the home since it has been registered with the Commission for Social Care Inspection. The homes deputy manager is Mr Tyahooa. Mrs Tyahooa is a qualified nurse with management qualifications and Mr Tyahooa has National Vocational Qualification in Care and Management Level 4. The home is judged as being managed to very high standard, which is evident through regular staff supervisions and appraisals, upkeep of records, feedback from service users and staff. Residents meet every two-month for a meeting. The home has a service development plan and has undertaken surveys to produce an annual development plan for the coming year. The home forwarded a completed Annual Quality Assurance Assessment (AQAA) to us. The AQAA was comprehensive, informative and has been used throughout this report. Residents are very vocal and are involved in the running of the home. The home has a fire risk assessment in place, which has been reviewed. The fire equipment has been serviced (09/08), fire alarm test (07/08), previous visits by the London Fire and Emergency Planning Authority were satisfactory. The Landlords Gas Safety Certificate was renewed in September 2008, The Portable Appliances Test Certificate was renewed in July 2008 and the Electrical Installation Certificate is up to date. The home has been visited by the Environmental Health Department in May 2005 and the visit was satisfactory. The home has a range of Health and Safety relating policies and procedures in place Care Homes for Adults (18-65 years) Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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