Care Home: 17-19 Edgeware Road

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What the care home does well On the day of the visit, the home was found warm, well lit and tidy. People who live in the home were found to be relaxed, well cared for and interacting with staff in an informal way. This led us to believe that a good relationship exists between staff and residents. The manager and staff were noted using their professional skills to deal with challenging issues exhibited by some residents with complex needs. The home is situated within the residential area of Staple Hill and this enables the home to support the service users to live a chosen life style. One person informed the inspector that he goes to the pub nearby to socialise with his friends anytime that he wanted. Individuals living in the home are encouraged and are supported to maintain links with family, friends and the community to ensure that they live as much a normal life as possible. One comment card we received for a relative stated, "As far as we know my brother is well cared for. He is always happy to go back when we have brought him home to see his mother and staff are always kind to him". What has improved since the last inspection? It was pleasing to note that the home has made efforts to meet all of the requirements made at the last inspection in order to provide a better service for the people living there. The home stated in their Annual Quality Assurance Assessment (AQAA) that staff are listening more to clients need, liaising more regularly with social workers, promoting independence and working toward set goals. The home is more conscious of people`s diets and providing appropriate menu planning including more fresh produce on a daily basis. New residents are assessed holistically and are assured that the home is able to meet their needs. Individuals living at the home are encouraged and are supported to maintain links with family, friends and the community to ensure that they live as much a normal life as possible. What the care home could do better: Whilst the requirements issued at the last inspection had been met the manager must ensure that the following concerns set out below are addressed. These concerns include: Individuals living in the home would enjoy a safer environment if the identified windows with faulty handles and producing drafts in the rooms are replaced or repaired. The Trust must also ensure that the French door in one of the houses that is difficult to open is repaired. The manager informed the Commission for Social Care Inspection that it has contacted the landlord through the Facility Manager for the repair or replacement of the windows. Whilst the home is waiting for a response from the landlord, it must ensure that risk assessment of the identified windows and door is undertaken to provide adequate protection to the residents. To ensure that people who live in the home are protected from harm and possible abuse, Protection of Vulnerable Adults from Abuse training update must be provided for all staff working at the home. To improve individuals` safety and, to prevent food poisoning, the fridge and freezer temperatures in the kitchen must be taken regularly.Furthermore to ensure that service users medication is protected medicine fridge must be repaired or replaced, regularly defrosted and accurate temperature recorded. Generic risk assessments of the home including hazardous areas in the lounges and service users bedrooms must be undertaken to ensure that people living in the home, staff and visitors are protected from potential harm. To adequately protect an individual who had recently fallen out side the garden the home must ensure that a risk assessment in place to support the individual to main his independence. CARE HOME ADULTS 18-65 17-19 Edgeware Road Staple Hill South Glos BS16 4LZ Lead Inspector Grace Agu Unannounced Inspection 20 November 2007 09:15 th 17-19 Edgeware Road DS0000003375.V351909.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 17-19 Edgeware Road DS0000003375.V351909.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. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 17-19 Edgeware Road Address Staple Hill South Glos BS16 4LZ 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) 0117 957 0404 0117 957 5117 admin@aspectsandmilestones.org.uk Aspects and Milestones Trust Rachel Hicks Care Home 17 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (17) of places 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 17 persons aged 19 years and over requiring personal care. May accommodate one named person with a Physical Disability (PD). Will revert back to LD when named person leaves. 21st July 2006 Date of last inspection Brief Description of the Service: The houses at 17-19 Edgware Road are properties run by Aspects & Milestones Trust, which is referred to in the report as The Trust. The houses at 17-19 Edgware Road were first registered as a nursing home for people with learning disabilities. However the registration changed in 1996 with the changing needs of service users to that of a Care Home. The houses are purpose built with off street parking. The Home is registered for seventeen people. The Edgware Road accommodation consists of seventeen single rooms split between the two houses. These are separately run. Each has it’s own staff group and is independent of the other with it’s own kitchen, dining /lounge and bathing facilities. There is a garden at the rear of the building that provides a small paved area for each house. Beyond this there is a larger, shared garden. The home is in a quiet cul-de-sac in a well-established residential area. The shopping area of Staple Hill is very close by with full public amenities. Staple Hill is on a main bus route to the city of Bristol. Fees range from £1035- £1035. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over eight hours and was undertaken as a part of Key inspection to review the care practice to ensure that it is in line with the legislation and that best practice is being followed at the home. It was also undertaken to review the requirements made at the last inspection and to ensure that they have been met. At the last inspection four requirements were made in relation to updating the complaints procedure, appropriate induction training for bank staff, regular fire drills for staff and ensuring that the worn carpet in house no 17 is replaced. It was pleasing to note that the home had made efforts to ensure that all the requirements were met. Whilst touring the building some individuals living in the house were observed getting ready to go out for their daily routine programmes. We looked at a number of records and spoke with three people who use the service and three staff members. The home Manager Rachael Hicks arrived later in the morning and assisted with providing information for the rest of the inspection process. What the service does well: On the day of the visit, the home was found warm, well lit and tidy. People who live in the home were found to be relaxed, well cared for and interacting with staff in an informal way. This led us to believe that a good relationship exists between staff and residents. The manager and staff were noted using their professional skills to deal with challenging issues exhibited by some residents with complex needs. The home is situated within the residential area of Staple Hill and this enables the home to support the service users to live a chosen life style. One person informed the inspector that he goes to the pub nearby to socialise with his friends anytime that he wanted. Individuals living in the home are encouraged and are supported to maintain links with family, friends and the community to ensure that they live as much a normal life as possible. One comment card we received for a relative stated, “As far as we know my brother is well cared for. He is always happy to go back when we have brought him home to see his mother and staff are always kind to him”. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst the requirements issued at the last inspection had been met the manager must ensure that the following concerns set out below are addressed. These concerns include: Individuals living in the home would enjoy a safer environment if the identified windows with faulty handles and producing drafts in the rooms are replaced or repaired. The Trust must also ensure that the French door in one of the houses that is difficult to open is repaired. The manager informed the Commission for Social Care Inspection that it has contacted the landlord through the Facility Manager for the repair or replacement of the windows. Whilst the home is waiting for a response from the landlord, it must ensure that risk assessment of the identified windows and door is undertaken to provide adequate protection to the residents. To ensure that people who live in the home are protected from harm and possible abuse, Protection of Vulnerable Adults from Abuse training update must be provided for all staff working at the home. To improve individuals’ safety and, to prevent food poisoning, the fridge and freezer temperatures in the kitchen must be taken regularly. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 7 Furthermore to ensure that service users medication is protected medicine fridge must be repaired or replaced, regularly defrosted and accurate temperature recorded. Generic risk assessments of the home including hazardous areas in the lounges and service users bedrooms must be undertaken to ensure that people living in the home, staff and visitors are protected from potential harm. To adequately protect an individual who had recently fallen out side the garden the home must ensure that a risk assessment in place to support the individual to main his independence. 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. 17-19 Edgeware Road DS0000003375.V351909.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 17-19 Edgeware Road DS0000003375.V351909.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): 1,2.4,5 Quality in this outcome area is good, The home provides information to prospective residents and their representatives and ensures that the admission process provides safeguards to meet the assessed needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and a Service Users Guide, which contained information, required by regulation. The service users guide is given to the prospective resident or their representative to enable them to make a choice of moving in to the home. The process of admitting a new individual is in place and functioning. Reviewing the newly admitted resident’s record showed that the manager attended several informal meeting at the individual’s previous house to assess his/her suitability. The manager informed the inspector that the resident visited Edgware Road about a several times and a couple of overnight stays to meet the existing residents to ensure that both parties are happy to live together. There were also meetings between relevant health professionals including the individuals Social worker. Discussions with some of individuals living in showed 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 10 that the residents were consulted about the admission of the resident and that they were happy for the person to live at Edgware Road. The new resident has a Statement of Terms and Conditions of his/her stay in the care file in a picture format. 17-19 Edgeware Road DS0000003375.V351909.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. Individualised care plans are provided for the residents to reflect their assessed needs and residents are supported to participate in the running of the home. Required support with risk assessments are provided for the residents to live independent lives with the assurance that information about them will be kept confidential. EVIDENCE: Three care files were reviewed at this visit and each care file contained an individual plan of care on how the needs of the person were being met. Information noted on one of the care file includes an ‘Essential Life Plan’ which provided detailed information about the resident’s likes and dislikes, important things in his/her life and things people need to know about supporting the person. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 12 The care plans are developed by the key workers with the individuals’ involvement where practicable and are regularly reviewed. One individual’s care file showed evidence of risk assessment in relation to going out to the community unaccompanied. The individual when spoken with confirmed that he goes out to have a drink in the pub. He stated that ‘things are a lot better I try to be careful. I go out when I like, I know what I am doing’. Another person with several episodes of staying out late and sometimes not returning to the home had a risk assessment in place including information on what measures that staff have to take if the resident fails to return to the home. The measures are supported with a missing persons policy. This clearly demonstrates that the home enables the residents to exercise their freedom of choice with well-managed, defined risk management strategies. However in one of the care plans some risk assessments needed updating. For example one individual’s risk assessment in relation to a recent fall had not been updated, furthermore, there was no risk assessment in relation to accessing the garden to support the individual with managing the risk due to poor mobility. A copy of the risk assessment undertaken to protect the individual was sent to the Commission for Social Care Inspection for review before this report was completed. The service users met at the home, looked well looked after and were noted accessing most areas of the home without restrictions. One individual confirmed that they are given opportunity to undertake tasks and that staff assist and support them to participate in the running of the home. People living in the home participate in the residents’ meetings and identify changes and improvements they would like to see in the home. Staff are familiar with the confidentiality policy. They are also aware of the possible information, which may have to be shared to protect people. Individuals living in the home are also aware that information about them is “private”. One individual said to the manager whilst discussing with the inspector, “I want to talk to you in private please”. 17-19 Edgeware Road DS0000003375.V351909.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): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities for personal development and are supported to maintain links with the community, family and friends. Their individual rights are respected whilst providing healthy diets at chosen times. EVIDENCE: The home is well-situated and it allows many people living in the home the opportunity of using the local community facilities daily. Review of the care records and discussion with the registered manager and staff showed that residents are helped to make choices, decisions and to take responsibilities for themselves. For example one person that chooses a life style that affects his health is regularly given a gentle reminder of the importance of looking after his health without undermining the person’s independence. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 14 On of the day staff was noted interacting with residents and supporting them to participate in activities at the home. Service users spoken with told the inspector that they liked the food and that they are able to choose what they like. The manager and staff confirmed that all residents are encouraged to make a choice at the beginning of the week when the menu is compiled however if on the day they don’t like what is on offer an alternative is provided. Meal times are flexible except when some one has to be out by a set time. During the visit the individuals living in the home were noted coming down into the kitchens throughout the day to have breakfast, lunch and to make drinks. The home has two kitchens, which were found to be clean and tidy. The foods in both fridges were in date. The freezer temperatures in the kitchen at no 17 had not been recorded; the manager is to ensure that the temperatures are regularly recorded to prevent the risk of food poisoning to the residents. Records show that some individuals have some form of employment. One individual stated that he is supported to work at British Aerospace on Mondays and helps out with the tills at Turmberies on Tuesdays Wednesdays and Thursdays to enable him to learn independent life skills. There are many other external activities available to the service users depending on their choice when they are at home. These included bingo, listening to music and watching videos. People who chose to visit the cinema, bowling and planned holidays are supported to do so. Individuals are able to attend the church of their choice in order to promote equality and diversity. One relative stated in the comment card sent to the Commission, “My relative has been very happy since becoming a resident at the home. He is taken on holidays and to shows and most days he is occupied with doing things he likes to do. Moving to Edgware Road has been the best thing that ever happened to him”. There is evidence that family links are encouraged. Entries noted in the visitors’ book confirm that for some individuals visits from friends and family take place regularly. One individual stated that they were missing visiting a family member due to sudden bereavement. People living in the home are supported to develop and maintain close relationships. Currently there is a couple that share a close relationship, 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 15 however, the risk assessment and information provided for them by the home was unable to prevent a recent incident. These have been reviewed to ensure that both are safe in such situations. 17-19 Edgeware Road DS0000003375.V351909.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, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports the residents as required and ensures that their emotional and physical health needs are met. Medication Administration practices are satisfactory. EVIDENCE: Some individuals and staff members were met at the home on the day of the inspection. The individuals looked very happy and well cared for. There was a warm interaction between the staff members and the individuals who were quick to inform the inspector that they were being supported very well. Evidence from the care files and discussion with the staff members show that the individuals are supported with their personal and emotional care and how these are carried out. One staff member was able to describe in comprehensive detail how one individual is supported routinely including the level of support provided by staff to ensure that the individual maintains independence. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 17 The staff member also described the individual needs and risk assessments in place to ensure that the needs were met. There is clear evidence in one individual’s care records that the health need was recently reviewed following an incident and that strategies were in place to reduce the risk involved. Review of care files and discussion with staff members show that service users are supported to manage their health as far as possible. Staff would accompany an individual for appointment if they wished. There are regular General Practitioner reviews and staff will only go into the consulting room if the service user is happy for the staff member to be there. Entries noted in the daily report evidenced how support and personal care was provided to reflect the care plans in place. The care plans noted were regularly reviewed to include reviews from the Day Care Services. There are clear procedures and appropriate arrangements in place for the receipt, storage, administration and disposal of medication in the home. The system was found generally satisfactory. Some individuals are able to self medicate and have been supported with risk assessment to enable them to maintain their independence. However reviews showed discrepancies in relation to the medicine fridge not working satisfactorily. The fridge temperature recording was below normal and was last recorded on 25/2/07. This is hazardous to the medicines stored in the fridge. The home must ensure that the fridge is repaired or replaced in order to protect the service users medicines. These discrepancies were discussed with the manager and a requirement was issued for the above to be remedied in order to protect the residents. Actions taken by the home to meet the above requirement was received at the Commission before this report was completed. Staff files reviewed showed that staff working in the home have completed a training update on medicine administration competency. Staff are aware of how to support individuals towards the end of life and time of death. 17-19 Edgeware Road DS0000003375.V351909.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. The residents are enabled to complain with the confidence that their views will be listened to and acted upon and that they are protected from abuse. EVIDENCE: There is a complaints procedure available in the home. The document contains information about the Commission for Social Care Inspection and is in an appropriate format relevant to the service users group. Whilst this document contained required information about how to complain updated details of the Commission for Social Care Inspection must be included to enable residents and their representatives to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. This information has been updated before the report was completed. There is a Aspects and Milestones Trust policy and procedure in regards to the Protection of Vulnerable Adults The Home also has a copy of South Gloucestershire’s policy and procedure for the Protection of Vulnerable Adults. In relation to a recent incident about alleged abuse of a service user by another individual, the incident was recorded and reported and dealt with under the Protection of Vulnerable Adults from Abuse procedure. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 19 Whilst the Home manager is awaiting confirmation in writing of the action plan agreed to ensure both individuals are protected, there was updated risk assessments in place and both individuals were noted relaxed. One of the individuals was unwell and was being attended by the Day support worker on the day. The manager stated that the complaint by the individual allegedly abused had been withdrawn by the individual concerned. A random selection of the service users money was counted all tallied against the records. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 20 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. adequate This judgement has been made using available evidence including a visit to this service. The home provides comfortable, safe clean and hygienic environment for residents to live in, however, it fails to protect them through lack of repairs to identified areas of the premises. EVIDENCE: The home is well suited for its purpose. It is conveniently placed in a quiet culd-sac and within easy walking distance of Staple Hill shopping area. The home is split into two houses and these are separately staffed and have their own communal spaces and kitchens. As there are only seventeen service users between the two houses the home falls within the recommended number in any given establishment. The houses are linked and both have passenger lifts. The premises do not provide respite or short-term care. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 21 The fire log was inspected and found to be in order. Fire appliances had been recently serviced and where needed, replaced. Concerns were raised about a number of faulty windows and door in both houses. The faulty windows produce draft in the service users bedrooms and lack of security. This situation is hazardous to the health and safety of the people who live in the home. The manager stated that the problem had been reported to the landlord through the facilities manager and that they are awaiting response. A requirement has been issued for this concern to be remedied to ensure that service users health and safety is not compromised. The laundry facilities are well away from the kitchens. The home is kept clean and free from offensive odours. 17-19 Edgeware Road DS0000003375.V351909.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): 31,32,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy good warm relationships with competent staff and are protected by the home through staff supervision. EVIDENCE: Staff records viewed showed that staff have attended medication competency training, first aid, food hygiene training and manual handling. The manager stated that majority of the staff have attended Protection of Vulnerable Adult from Abuse training in the last three years. The manager also told us that Aspects and Milestones has reviewed POVA training and all staff will be receiving yearly update as apart of statutory training. On the day of the inspection, one resident met at the home was noted being supported by one staff member. The relationship between the staff member and resident was warm and friendly. The staff member stated that all staff working at the home are aware of residents needs and have been at the home for a long time. 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 23 The rota showed that the home is adequately staffed to meet the residents’ needs. The manager stated that the employment of an administrative support has given her the opportunity to spend more time with the service users. All staff records viewed had job descriptions to ensure that they were aware of their roles and responsibilities. One staff member spoken with on the day stated that there was good communication between all staff and that this has enabled them to provide support and good care to meet the complex needs of both individuals. To enable us to form judgement about the how staff care for the people living in the home we sent comment cards to the relatives, health professionals and other visitors to the home. These are some of what they told us: “Edgware Road staff give a high standard of care, meet the needs of the individuals, communicate effectively and work well as a team”. “I found 17-19 Edgware Road to be one of the best care homes in the area. They manage to deal with complex people in an individual and caring way”. “In my opinion and experience, this home for people with learning difficulties and other diagnosis is well run. The clients are treated with respect and courtesy”. Discussions with staff members and evidence from staff records showed that the staff have received regular supervisions to enable them to perform their duties effectively and to discuss issues of concern in relation to residents needs. There was no new staff recruited since the last inspection however one staff records viewed had all the necessary recruitment documentation to ensure that residents are protected. 17-19 Edgeware Road DS0000003375.V351909.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. The home is well run by a competent manager who ensures that residents are adequately protected through appropriate health and safety measures. EVIDENCE: The Home Manager, Rachael Hicks is competent and well qualified. Ms Hicks is a registered nurse and has completed National Vocational Qualification (NVQ) at level 4 in care and management. Evidence noted from staff interaction and team bonding on the day of the visit showed that the home is well run in the absence of the manager. Staff met on the day stated that the Manager would be in later, however, staff members provided the inspector with the records requested. The staff member 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 25 showed an in-depth knowledge of all the residents discussed and provided explicit information on complex needs of an individual. One staff member stated that the manager is a good manager, she is approachable and would listen to any concerns staff may have. Staff work as a team, there are regular staff, and resident meetings. Evidence of measures used to monitor the quality of service provided at the home-included regular care plan reviews, risk assessment reviews and regular staff supervisions and staff training. The home’s policies and procedures reviewed included confidentiality, challenging behaviour, missing persons, supervision, Protection of Vulnerable Adults and Personal relationships and sexuality. These policies are due for review to ensure that staff are kept up to date in terms of information regarding how to provide continuity of care to the people living in the home. The home had various health and safety measures in place to ensure that the residents are adequately protected. These include regular fire drills and well maintained fire logbook. Gas inspection was carried out on 07/11/07, Legionella Certificate was issued on 21/06/07, and Portable Appliance Testing of electrical appliances was carried out on 25/06/07. Accidents book showed that all accidents were well documented and followed up and when required a Regulation 37 notification form is used to inform the Commission for Social Care Inspection of serious injuries to the service users. Records inspected were seen to be up to date with the exception of the need to review risk assessments in regards to service users falls and accessing the garden. This has been noted earlier in the report. 17-19 Edgeware Road DS0000003375.V351909.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 3 5 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 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 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13 Requirement Ensure that the risk assessment in respect of identified faulty windows and door is undertaken to protect the people living in the home. Timescale for action 21/11/07 2. YA23 18 Provide staff with training update 21/12/07 on the Protection of Vulnerable Adults from Abuse in order to protect the service users. Ensure that the fridge and freezer temperatures are taken and recorded regularly to protect the individuals living in the home from food poisoning. Replace or repair the medicine fridge and ensure that it is regularly defrosted to give an accurate temperature reading. Ensure that generic risk assessment of all places service users have access to including the lounges are undertaken in order to protect the service users. Ensure that risk assessment is in DS0000003375.V351909.R01.S.doc 3. YA42 13 19/12/07 4. YA20 23 19/12/07 5 YA24 13 30/12/07 5 YA9 13 19/12/07 Page 28 17-19 Edgeware Road Version 5.2 place for identified individual following falls. Review must be undertaken subsequently. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 17-19 Edgeware Road DS0000003375.V351909.R01.S.doc Version 5.2 Page 30 - 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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