Inspection on 13/02/07 for Valley Way House

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

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

CARE HOME ADULTS 18-65 Valley Way House Dollis Valley Way Barnet Hertfordshire EN5 2UL Lead Inspector Wendy Heal Key Unannounced Inspection 13th February 2007 10:00 Valley Way House DS0000068273.V323071.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 Valley Way House DS0000068273.V323071.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. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley Way House Address Dollis Valley Way Barnet Hertfordshire EN5 2UL 020 8441 6515 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) London Borough of Barnet Roseline Oluchi Anyanwu Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26 January 2006 Brief Description of the Service: Valley Way House is a six- bedded care home on the New Fieldways complex, situated within the Dollis Valley Way estate in high Barnet. The home is a respite unit offering short-term care to adults from the age of 18 to 65 years of age, with severe learning difficulties, sensory impairments and autism whose behaviour challenges other services. One bedroom is specifically available for emergency placements. There are six single bedrooms, which are en-suite. There is also an integral lounge and dining room looking onto the garden. There is also a well- equipped kitchen and laundry room. The home is accessible to wheelchair users. The home has a minibus within the complex. Notting Hill Association manages the building and the London Borough of Barnet operates the home. The stated aims of the home are to provide respite care for adults who have learning difficulties and physical difficulties. The last inspection report and purpose and function document are available for inspection within the homes entrance hall. The fees are £255 pounds per night, which is subsidised by the local authority. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took approximately 7 hours. The manager Roseline Anyanwu assisted the inspector throughout the day. The inspector undertook a tour of the building, spoke with four service users and observed the interaction between the service users and staff. The inspector spoke with members of the staff team. Further information was obtained by an inspection of the documentation kept in the home, including care plans assessment information and health and safety documentation. The inspector would like to thank service users present during the inspection, the manager and staff for their openness and participation. What the service does well: There is a clear statement of purpose, which ensures prospective service users and their families have sufficient information available to them to make an informed choice about whether the service can meet their individual needs. There is a range of clear assessment information, which ensures the service can meet service users needs prior to admission. There are detailed and up to date care plans, which, ensure that staff can meet service users needs in a consistent way. There are clear risk assessments in place, which identify potential risks for service users, which ensures that the health safety and welfare of service users and staff is taken seriously. Service user information is handled appropriately which ensures that service users confidentiality is respected. Service users have established links with the local community, which allows for social integration. Service users take part in a range of stimulating activities, which provides service users with the opportunity for personal development. Service users are provided with all of the necessary equipment to maximise service users independence. Service users benefit from a hygienic comfortable home, which service users health and wellbeing is safeguarded. Valley Way House DS0000068273.V323071.R01.S.doc ensures that Page 6 Version 5.2 The complaints book had information, which, had been clearly recorded, and action had been taken within appropriate timescales, which ensures that service users complaints are taken seriously. The home has satisfactory adult protection policies and staff have undertaken adult protection training, which ensures that staff are fully informed in relation to adult protection procedures, which benefits the wellbeing of service users. The home benefits from an experienced stable staff team, which improves the quality of care provided to service users. Staff are receiving regular supervision, which ensures staff are provided with the opportunity for personal development. Staff files were inspected and contained all the necessary criminal records bureau checks staff references and staff identification records, which ensures service users are protected from potential abuse. What has improved since the last inspection? What they could do better: The current mini bus needs to be updated to ensure that service users can more effectively access the community on a consistent basis to ensure service users opportunities within the community are fully maximised. A good practice recommendation has been made in relation to this. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 7 The quality of food made available to service users needs to be reviewed to ensure that nutritious food that does not contain high levels of salt and sugar are available to service users. A requirement has been made in relation to this. The entrance to the home has two glass sliding doors, which do not promote a homely environment and do not promote the privacy of service users. A requirement has been made in relation to this. The service users cannot function independently within the garden if they use a wheelchair as the garden is not level and therefore service users independence is compromised. A good practice recommendation has been made in relation to this. The effectiveness of Notting Hill the maintenance association needs to be discussed with senior managers within the organisation to ensure that the quality of care provided to service users is not compromised due to their slow response. A good practice recommendation has been made in relation to this. When the fire alarm is tested the gas supply is cut off within the home to safeguard service users and staff from potential danger. However staff informed the inspector that to reset the appliances takes considerable time. The inspector would like the manager to consult with relevant professionals to see if any other measures can be put in place to make the system more effective. Staff must be fully informed in relation to how the system operates. A requirement has been made in relation to this to safeguard service users and staff. Thermostatic valves must be fitted to ensure service users and staff are protected from scaling, as the water temperature is not currently controlled. A requirement has been made in relation to this. 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. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 8 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 Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are given the information they need to make an informed choice about whether the respite service is suitable for them and their needs are addressed prior to them receiving the service. EVIDENCE: The inspector looked at the new statement of purpose, which has been updated due to the fact that this service has moved to newly built accommodation which ensures that prospective service users and their families have sufficient information available to them regarding the service to make an informed choice about whether the service can meet their individual needs. The service user guide is well laid out and is available in large print, if required to ensure it is accessible to all service users. Three service users files were inspected. All contained a range of assessment information, which ensures service users needs can be met prior to admission. The referring authority had undertaken assessments. Valley way staff also complete their own assessments at the point of admission. The inspector saw evidence that a nurse’s assessment had also taken place to ensure that one identified service users needs could be fully met. The home obtains additional information from the identified service users school before the service user attends their first respite stay. A social workers assessment determines how Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 10 many nights each service user receives at Valley Way each year and this information is available on the individual service users file, which ensures clear procedures are in place in relation to the allocation of resources. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 11 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): 6,7,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and aspirations are clearly set out in their care plans to ensure their needs are consistently met. The service is good at enabling service users to make decisions for themselves about what they want to do and when they want to do it. Service users risk assessments did contain accurate information relating to the service users needs, which results in consistent standards of care. Service users information is stored appropriately and kept secure which ensures service users confidentiality is safeguarded. EVIDENCE: Three service users care records were inspected. The service users care plans were detailed. The care plans were based on individual current and changing needs. The care plans of the identified service users evaluate all aspects of service users needs for example family background, religious and cultural needs, health communication and personal relationships, to name a few. There is also a separate section in relation to current goals which ensures that Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 12 service users needs can be met as information is clearly recorded which assists staff to work in a consistent way. The plans specify the areas in which service users make decisions about their lives with assistance. The inspector saw evidence that care plans are being reviewed and are being sent to service users families for them to read and sign if they agree with the contents, which ensures that service users families are fully informed and involved in the care plan process which makes them feel valued. The risk assessments to show potential risks for service users are being reviewed the areas covered include personal safety, mobility, environment, and the use of bed - sides, cooking, other service users, personal care and dress code which ensures that the health safety and wellbeing of service users is taken seriously. The inclusion of educational statements, school reviews and programmes of school activities within the service users files established an all –round picture of service users, which means that service users needs are being met in a holistic way. Service user information is handled appropriately. The main files are kept in the two offices and information kept on the computer is accessed by a password. The inspector observed the level of confidentiality in the home and is satisfied that the staff working at Valley Way House keep all information regarding service users secure which ensures their confidentiality is respected. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users have the opportunity for personal development. Service users quality of life is improved because of their established links with the local community. Service users take part in a range of stimulating and appropriate activities. The opportunity for service users to undertake activities outside the home has been limited for a period of time, as the minibus has not been functioning effectively. Service users are offered varied meals but the quality of food available is not always of a high standard service users are always eating nutritious food. EVIDENCE: On the day of the inspection service users activity records were inspected. While service users stay at Valley Way they undertake their usual daytime activities, e.g. Day Centre and school activities. During school holidays and at weekends the staff provide daytime activities. The inspector saw evidence of art and craft materials, a play station, a DVD player and computer, which enables service users to develop their individual skills. The new home has a Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 14 sensory room, which contains musical instruments, soft toys, strobe lighting, and a new large flat screen television, which benefits service users who have a visual impairment to watch television more effectively as they have a larger screen to view the picture. The inspector noted that staff interacted appropriately with service users. One identified service user was preparing a meal with the service user in the kitchen this interaction was warm and sensitive and it was clear that the staff have a good understanding of service users needs which assists to make service users feel secure during their stay. The opportunity for service users to maximise their enjoyment of external activities and increase their personal development have been limited to some degree as the staff team informed the inspector that the minibus has not been functioning effectively and could not be used as the problem took some time to rectify and limited service users involvement in the community. The bus can only accommodate one wheel chair user at a time, which limits service users choice as to whom they travel and socialise with. A good practice recommendation has been made in relation to this. The kitchen has low level worktops and cupboards, which allow service users to become fully involved in the food preparation within the home. The inspector saw evidence of one service user assisting staff to prepare the evening meal, which, makes service users feel valued and increases their independence. Service users choices and involvement are further encouraged by the use of pictorial symbols on the doors of the kitchen cupboards to allow easy identification and access to their chosen items. The service users care plans detailed service users’ likes and dislikes and cultural and religious preferences and information in relation to service users individual allergies and special diets. The inspector saw evidence that service users cultural and religious preferences were being respected as one identified service user who eats kosher food uses separate utensils in relation to meat and dairy produce. The utensils are colour coded which ensures his rights are respected. However the staff’s ability to meet the needs of service users and provide a varied and balanced diet and meet service users cultural needs has become more difficult to achieve due to the reduction in the food budget and the inspector was concerned that the food brought and identified in the freezer was economy labelled food which is often high in sugar and salt the inspector has never seen this quality of food available in the home previously. A requirement has been made in relation to this. The kitchen was clean and tidy and hygienic and means that service users health and wellbeing is safeguarded, as they are protected by good health control procedures. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 15 Food stored in the fridge was within its sell by date and correctly labelled which protects the wellbeing of service users, as they are not eating out of date food. The fridge and freezer temperatures had been recorded and were found to be in order, which means that food is being stored at correct temperatures and cannot deteriorate and impact on service users health. The inspector saw evidence of colour coded chopping boards, which prevent cross infection when food preparation is taking place. The home had an adequate supply of the necessary specialist equipment spoons, bowls, and drinking cups which are required to ensure that service users independence is maximised in relation to them eating their meals. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in a way they prefer and require The health care needs of service users are met. The medication at Valley Way House is well managed, promoting the good health of service users. EVIDENCE: The service users all have access to specialist healthcare when required. The staff at Valley Way House receive support from professional medical staff to assist with the needs of service users when it is required which ensures service users health needs are met. The medication records were inspected and found to be in good order, the medication is signed for on the Medication Administration Record sheets, which ensures that professional practice is being followed which benefits service users. The medication cabinet was inspected and all medication was found to be in order. There is a clear medication policy in place, which ensures that staff are provided with adequate information to enable them to follow professional procedures and improve the quality of care provided to service users. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 17 Service users were appropriately addressed at the time of the inspection, which promotes a positive self-image and increases service users self- esteem. At the time of the inspection three service users were mobile and two required direct assistance. The inspector saw clear evidence in relation to how the young people preferred their personal care to be delivered, which means their individual wishes are being respected. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 18 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 views are listened to and acted upon since the recording of complaints and action taken is adequate. Service users are protected from abuse neglect, and self-harm. EVIDENCE: At the time of the unannounced inspection the inspector looked at the complaints file and found two complaints had been made since the previous inspection they had both been responded to appropriately and were clearly recorded which ensures that service users complaints are taken seriously. The staff at Valley Way have attended adult abuse and protection of vulnerable adults training. The manager and deputy manager had completed their training for trainers course and provide training to staff on behalf of the Borough of Barnet to staff. The home has a satisfactory multi agency adult protection policy, which includes a whistle blowing policy and no secrets information which ensures that staff have been fully informed in relation to professional practice to be followed which improves the quality of care provided to service users. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,29,30, 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 clean environment. However the entrance to the home does not promote a homely environment. Bedrooms are starting to be individualised. The bathrooms adequately meet service users needs. Service users have the specialist equipment; they require which maximises their independence. EVIDENCE: The Valley Way respite service has been relocated to a new building, which is located a short distance away from the current service that has now been demolished. The new building has six bedrooms with tracking hoists and ensuite, bathrooms, which means that the service users have the opportunity for privacy when personal care tasks are being undertaken. A fully accessible shower room is available and there are also three separate toilets, which ensure there are adequate facilities available to meet the needs of service users. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 20 The home has a lounge and dining area and kitchen, which has low cupboards and work surfaces to ensure service users have full involvement in activities taking place within the kitchen, which, increases their self, help skills. There is also a sensory room that is fully – equipped including bubble tubes, strobe lights, glitter balls, this room and its facilities provides an opportunity for service users individual sensory needs to be met, which, increases their personal development. The home is fully accessible all doorways and hallways are wide enough for those service users who use wheelchairs to operate independently within the home, which allows them to be as independent as possible and increases service users self-esteem. The home has a lift to the first floor only. Laundry facilities are kept separate from food preparation and the washing machine has a sluice facility, which ensures sufficient infection control is being followed. The home has a mobile hoist to assist service users with limited movement to be transferred in comfort. The hoist had been serviced which, ensures that health and safety requirements are being met and service users and staff are protected from harm as the equipment is fit for use. The home currently has two offices available one is used by the staff team and the other by the manager and deputy manager. The entrance to the home consists of two glass sliding doors to allow easy access however they do not promote a homely environment or privacy as passers by have a clear view of the downstairs of the home and can witness all activities taking place. A requirement has been made in relation to this. The garden is much smaller than that of the previous accommodation and is not level which means service users who use wheelchairs cannot be fully independent, as they would require assistance from staff to move freely around the garden. A good practice recommendation has been made in relation to this. A tour of the home showed an appropriate standard of cleanliness. Bathrooms and toilets were free from offensive odours, which ensure the service users have a pleasant place to live. On the day of the inspection the inspector was informed that the hot water was not working and an identified member of staff was attempting to contact Notting Hill Association who manage the maintenance work within the home on three separate numbers from the time of my arrival in the morning. At four Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 21 P.M a member of staff from the maintenance department stated a fax had been sent and after much discussion the manager and inspector was informed that the problem would be rectified the following day. The manager and staff team then discussed how they were going to meet the personal care needs of service users. The inspector is very concerned in relation to the delayed response and has requested that these concerns are passed on to the organisations area manager to allow appropriate action to be taken. A good practice recommendation has been made in relation to this. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff are well qualified and there is a stable staff team in sufficient numbers to support service users and assist them in meeting their assessed needs. Service users are protected by an adequate recruitment procedure, which is operated by the home. Staff are well supported and supervised which benefits the quality of care provided to service users. EVIDENCE: The homes rota showed adequate members of staff on shift in relation to the number and needs of the current service users in the home which, means service users needs can be met. The staff on duty matched those on the rota which, ensures that service users are supported by a stable staff team who are familiar with the service users needs, which improves the quality of care service users receive. The manager has been in post for an established period of time and has completed her access to work course a postgraduate certificate in management and NVQ level 4, which ensures that the home is managed by a knowledgeable professional person, which benefits service users as the home is managed effectively. Staff members have completed their NVQ level 3, which increases their knowledge and skills, which benefits service users Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 23 There is evidence that staff have been trained in the administration of medication including the administration of rectal Diazepam, food hygiene, first aid, challenging behaviour, manual handling, person centred planning, epilepsy awareness, holistic behaviour therapy, equality and diversity, autism and Makaton training. This will ensure that those service users that use the respite service and have autism or particular communication needs can be reassured that their individual needs can be met. The staff supervision records were inspected. Staff are receiving supervision, which ensures that staff have the opportunity for personal development and are supported to support service users in a consistent way. Regular staff meetings are taking place, which ensures that staff have the opportunity to express their views. The manager can ensures that effective communication systems are in place, which benefits the quality of care provided to service users as staff work together in a consistent way. The inspector observed a motivated staff team working to develop professionally and support service users to experience a good standard of care, which makes service users feel valued. The staff members spoken with expressed the fact that they find it difficult working on two floors rather than all service users living on one level but the inspector was impressed with the efforts that were being made to accommodate the arrangements in the new home to ensure these changes do not impact on service users. Staff files were inspected and contained all the necessary criminal records bureau checks, staff references and the required staff identification records, which ensures service users are protected from potential abuse. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. Service users benefit from an open and transparent management approach, which promotes person centred- working in ensuring the needs of service users are promoted. Service users can be confident that their views underpin all self- monitoring review and development by the home. The health safety and welfare of service users and staff are not fully promoted. EVIDENCE: During a tour of the building the inspector became aware that due to the current building works taking place next door to the new home the foundations were being affected and were impacting on the drainage system of Valley Way House and this was causing on going difficulties and this does not benefit the health safety and wellbeing of service users. The manager confirmed that she has had a discussion with the builders and the difficulty is being rectified. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 25 A range of health and safety documentation was seen including: the water storage system that had been professionally inspected to minimise legionella, which protects the wellbeing of service users and staff. Regular fire drills, point testing and fire training had taken place. At the time of the inspection the inspector became aware that when the fire alarm is tested all of the gas within the home is cut off automatically as a safety measure. The staff have to reset all the gas appliances, which staff informed the inspector takes considerable time to do. The inspector would like the manager to consult the relevant professionals in relation to this to see if any other measures can be put in place to make this system easier to use. The manager must ensure that if this system has to remain in its current form that staff are fully informed in relation to what they need to do to restart the gas supply and why this system is in place. A requirement has been made in relation to this. The manager must ensure that thermostatic valves are fitted to ensure that the water temperature is controlled to prevent scalding of service users and staff. A requirement has been made in relation to this. The homes gas safety and electrical installation certificate were inspected and found to be in order, which protects the health and safety of service users and staff. The manager is currently establishing the service users and staff in their new premises and when all parties have settled in their new premises the manager will undertake a quality assurance audit. A requirement has been made in relation to this. Staff appraisals had taken place, which assists the staff’s personal development and service users benefit from the staff developing their skills and knowledge as the quality of care provided improves. Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 27 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 YA17 Regulation 12 (4) (b) Timescale for action The Registered Provider must 10/03/07 ensure that the quality of food offered to service users is reviewed. The Registered Provider must 10/03/07 ensure that action is taken to ensure that the entrance to the home promotes a homely environment. Action must be taken to ensure that the glass doors at the entrance of the home do not impact on service users privacy. The Registered Provider must 15/03/07 consult the relevant professionals to see if any other measures can be put in place so that when the fire alarm is activated a more effective system can take place to reinstate the gas supply. The Registered Provider must also ensure that staff are fully informed in relation to how the fire alarm system operates. The Registered Provider must 15/03/07 ensure that thermostatic valves are fitted. The Registered Provider must 15/04/07 ensure that a quality assurance DS0000068273.V323071.R01.S.doc Version 5.2 Page 28 Requirement 2 YA24 12 (4) (a) 3 YA42 13 (4) (a) 4 5 YA42 YA39 13 (4) (a) 35 Valley Way House audit is undertaken. 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 2 Refer to Standard YA13 YA24 Good Practice Recommendations The inspector recommends that the minibus be updated to ensure that it is more effective in assisting service users to access the community consistently. The Inspector recommends that the garden be levelled to allow those service users who use wheelchairs as part of their daily lives to be as independent as possible in relation to accessing the garden. The Inspector recommends that the concerns in relation to the slow response of Notting Hill are reported to the area manager for appropriate action to be taken. 3 YA42 Valley Way House DS0000068273.V323071.R01.S.doc Version 5.2 Page 29 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. 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