Care Home: 94 Station Road

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What the care home does well The home provides a high standard of care and support to a group of residents who have a range of complex care needs. The residents feel that they are supported as far as possible to maintain their independence. They also feel that they are able to make choices in their daily lives and the staff respect their views. One person said, "this home is nice, it is very nice". The staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their support needs. The residents were also observed to have a good relationship with the staff. The residents are supported to have their individual needs met by a key working system. They are also supported to access a wide range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well-established and very stable team of staff who are being supported by an acting manager. The home is very comfortable and homely and the residents each have their own room that is personalised to their taste. The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. What has improved since the last inspection? Since the last inspection the following requirements have been met. The residents have been supported to have an optical check and actions agreed at their review meetings have been incorporated into their care plans. The recording of medication in the home has been made clearer. The environment in the home has been greatly improved including the replacement of carpets in communal areas. The staff now have two written references and their training is up to date. A quality assurance exercise has taken place in the home, although it needs to incorporate a wider range of views. What the care home could do better: A few areas for improvement were identified at this inspection. In terms of the residents contracts need to be made available between the home and the resident to clarify the details of the service provided. Guidelines also need to be prepared when residents take an "as and when" medication to ensure staff know when this should be given. The care plans need to be put into a userfriendly format so they are more accessible and meaningful for the residents. Some residents should be supported to review and possibly reduce the number of building society accounts they have for their personal monies to simplify the systems being used and help avoid error. Staff need to have a record to show they have completed their induction. They also need to be supported with regular individual supervision sessions. The manager needs to complete the registration process. The quality assurance system needs to be reviewed to incorporate a wider range of views including relatives and care professionals associated with the home. CARE HOME ADULTS 18-65 94 Station Road Hendon London NW4 3SR Lead Inspector Jane Ray Key Unannounced Inspection 7th February 2008 01:00 94 Station Road DS0000010531.V357562.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 94 Station Road DS0000010531.V357562.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. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 94 Station Road Address Hendon London NW4 3SR 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) 020 8202 7621 020 8202 7621 bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood ** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th November 2006 Brief Description of the Service: 94 Station Road is a registered care home accommodating five adults with learning disabilities. The home is owned and run by Norwood a Jewish Charity that provides a service to children, adults and their families. The home is a large two storey domestic premises that is well decorated and maintained. The communal areas are situated on the ground floor and consist of a lounge, kitchen/diner and conservatory. One service user has a ground floor bedroom with an adjoining toilet/shower room. The staff facilities and four other bedrooms are on the first floor with adequate bath/toilet facilities. The home has good access to shops and public transport facilities and is a short walk away from Hendon Central tube station. The stated aim of the home is to provide 24-hour care in a homely environment where the priority is given to the establishment of safe secure and nurturing relationships between service users and members of staff. At the time of the inspection there were six service users living in the service. The current range of fees in the home is from £745 - £1147 a week. A copy of this report can be obtained direct from the provider or via the CSCI website (web address can be found at page two of this report. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection took place on the 7 February 2008 and was unannounced. The inspection lasted for three and a half hours and was the key annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to speak to and observe the support given to all of the current residents. The inspector was also able to spend time talking to the deputy manager and another member of staff who were both working in the home at the time of the inspection. The inspector did a tour of the premises and also looked at a range of records including resident records, staff files and health and safety documentation. The home had provided the inspector with a completed self-assessment questionnaire (AQAA) prior to the inspection. What the service does well: The home provides a high standard of care and support to a group of residents who have a range of complex care needs. The residents feel that they are supported as far as possible to maintain their independence. They also feel that they are able to make choices in their daily lives and the staff respect their views. One person said, “this home is nice, it is very nice”. The staff demonstrated a good knowledge of the people living in the home and were able to recognise their individual needs, especially in relation to their support needs. The residents were also observed to have a good relationship with the staff. The residents are supported to have their individual needs met by a key working system. They are also supported to access a wide range of educational and leisure activities based on their individual interests and this enables them to have participation in the local community. The home has a well-established and very stable team of staff who are being supported by an acting manager. The home is very comfortable and homely and the residents each have their own room that is personalised to their taste. The people living in the home are protected and supported by the effective use of policies and procedures including medication systems, adult protection procedures and health and safety procedures. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will be assessed and that the service can meet their needs. They are also provided with information about the home in order to help them decide if the service is where they want to live. EVIDENCE: The statement of purpose and service user guide were inspected. Both of these documents are in a user-friendly format and are clearly written, accurate and contain all the necessary information. The inspector looked at four case notes for people living in the home. They have comprehensive assessments prepared by the home that look at all aspects of their physical, social, cultural and emotional needs as part of the care plan. These assessments are completed to a high standard and reflect the detailed knowledge the staff have of the residents individual needs. This provides valuable information for staff to enable a holistic view of each 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 9 individual to be understood. The residents also have a brief profile available that is clear and easy to understand. The inspector observed that the staff were supporting the residents in an appropriate manner that reflected their knowledge and understanding of their individual needs. The residents were also observed to be comfortable and relaxed within their home environment. Two of the residents told the inspector how they were very happy in the home and felt well supported by the staff team. One person said, “the staff are really lovely, if I need advice with something they are all good”. The residents all moved to the home when it opened and there have been no admissions to the home during this time. This information was also reflected in the AQAA completed by the home. Norwood does however have a comprehensive admissions procedure that was inspected and this includes opportunities for potential residents to spend time visiting the home. The inspector checked the contracts available between the home and the residents. Whilst a format was available for these contracts in the service user guide, no individual contracts could be found for each resident. This was also confirmed by the deputy manager. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 10 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): Standards 6,7,8 and 9 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home feel able to have control and make decisions in their daily lives. Each person has a care plan but there is scope for greater ownership of this plan by the residents so they feel it reflects their individual aspirations. EVIDENCE: Four case notes were inspected were inspected for people living in the home. Each person has a detailed individual person centred care plans. These reflect the decisions made at each persons review meeting where they are supported to make decisions about their personal goals. This process is facilitated by a separate meeting, that takes place between the resident and their key worker prior to the review meeting. This is used to record what the resident wants to address in the main meeting. The review meeting takes place with the care 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 11 manager approximately once a year and there is also a review meeting arranged by the home on a six monthly basis. These review meetings were clearly recorded and demonstrated multi-disciplinary working. It was noted that for two of the residents that no minutes of their review had been provided by the care manager although the home had prepared it’s own record of the meeting. It could be seen that goals agreed at the review meeting, particularly around activities had been incorporated into the care plans. It was observed that the care plans were very long detailed documents. Whilst they were very thorough they were not very user friendly. One resident said “I understand my care plan and sometimes I look at it with staff”. Another person said, “I don’t look at my care plan but I go to the review meeting”. The care plan goals are clear and easy to understand and are monitored on a monthly basis. These goals focus on supporting the residents to gain greater independence and to look a how their lives can be further enhanced by improved activities or by addressing healthcare or emotional issues. The four residents all had a named key worker and they are involved in maintaining the care planning documentation. All the residents spoken to were able to tell the inspector the name of their key worker and what activities they did together. One person said “I go out regularly with my key worker”. In addition one staff member who was interviewed was able to fully describe their role as a key worker and this role was being performed in a very comprehensive manner and included contacting care professionals, keeping relatives informed and ensuring the residents choices are fulfilled. One of the people whose case notes were inspected could at times have complex behavioural needs. This person has guidelines describing these behaviours and this enables the staff to identify when the service user is distressed and what action they should take in response to this situation. These guidelines were clear and could be followed by the staff team. The inspector spoke to the deputy manager who described how the staff team were able to meet this persons needs. Some of the residents have restrictions in place, for example some people need to have support to manage their personal money or need sharp kitchen utensils held in a place of safety. The reasons for these restrictions are recorded in their care plan and risk assessment. One person was able to describe how the staff support her to manage her personal monies and to keep within an agreed budget. The four resident case notes inspected all included comprehensive individual risk assessments covering all areas of potential risk and this identified what action the home would take in response to the identified risks whilst at the same time promoting each service users independence. These covered a number of areas including accessing the community, safety during food 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 12 preparation and mealtimes and bathing for example. It was noted that risk assessments had been updated to reflect issues of vulnerability arising from an adult protection referral. Throughout the inspection the service uses were observed being consulted about decisions concerning their daily lives. This included being asked what they wanted to drink and when they felt ready to go out. The record of the resident meetings was inspected. These do not take place very regularly but one resident said “we make lots of decisions at the meetings”. The staff said that most decisions are made when everyone sits down to eat together in the evenings. The AQAA completed by the home also explained that the residents had been invited to join a self-advocacy project being run by an organisation called People First and the deputy manager said two of the residents are going to these meetings. The AQAA prepared by the home also identified that there was scope for residents to be more involved in decision-making processes in the home. 94 Station Road DS0000010531.V357562.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): Standards 11,12,13,14,15,16 and 17 People using this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported to have full and active lifestyles, both in the home and in the community that reflect their interests and offer opportunities for the development of new skills. They also develop and maintain family and personal relationships. EVIDENCE: The residents explained that they access a range of activities based on their individual needs and interests. This includes going to college, attending a number of sessions at resource centres and supported employment. One person explained how he attends two different colleges to learn French and computer skills. Another resident talked about his courier work. During the 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 14 inspection the residents were observed returning from work and college and participating in a computer class in the home with a tutor. The AQAA prepared by the home said that they are hoping in the next year to encourage some of the residents to try some job taster sessions through the Norwood Adult Opportunities Service to further develop their employment skills and experience. The residents also talked about the many leisure activities they enjoy including going to the theatre, bowling, cinema and eating out. Some of these activities are organised by a Norwood social club called Links. One resident said, “I enjoy going to the library or buying books to read”. Another resident showed the inspector her dog and then took the dog out for a walk. One other resident showed the inspector his model trains. The service offers the residents lots of opportunities to develop their independent living skills. One resident told the inspector about how they shared the shopping, cooking and cleaning between the group and everyone participated with support from staff. One resident said “I cook on a Saturday night and I am good at making fish balls”. Another resident said, “I do my own laundry”. The residents were observed making drinks and preparing a snack in the kitchen. The residents were able to tell the inspector how they enjoy practising their religion. This includes a traditional meal on a Friday night and they all enjoy the festivals. One resident said “I usually go to my mothers for Passover” and another said, “I sing in the synagogue choir”. The staff member spoken to said that the staff had received training on the cultural and religious needs of the residents and felt comfortable in supporting the residents in their daily lives. All the residents were able to tell the inspector how they had enjoyed their holiday in Spain. The deputy manager said that other breaks also took place individually and with relatives. The deputy manager explained that all of the residents have contact with their families or friends. They are made welcome in the home or residents are supported to go to their family homes. One resident said “I go to visit my mother at the weekend and I usually travel on the bus”. Another person said, “I see lots of relatives”. One resident said she goes out to see her friend and another said he meets his friends at Links. The deputy manager explained that a male volunteer visits each month and spends time with some of the men going to the pub and playing pool. It was observed that there was a friendly atmosphere in the home with the staff chatting to the residents. The residents were observed to be very relaxed with the staff and were keen to tell them about their activities that had taken place. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 15 The residents explained that they are able to have flexibility in their routine. One resident said “I go to bed at different times because I like to watch the television and at the weekend I get up later”. The residents talked about the food they prepare. The deputy manager explained that the residents each choose a meal at a weekly residents meeting and then are supported by staff to prepare the meal. They all follow a healthy eating plan. The residents spoken to also told the inspector about how they choose and prepare the meals. One said “we had lovely pancakes the other night and sometimes we have a take away”. The AQAA completed by the home said that in the last year they had invited a nutritionist to carry out some joint training with staff and residents to explore healthy ways of eating and develop menus that reflect this. 94 Station Road DS0000010531.V357562.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): Standards 18,19 and 20 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will receive personal and healthcare based on their individual needs and choices. Residents are supported to attend healthcare appointments and take their medication. EVIDENCE: It was observed during the inspection that the residents were given support with their personal care based on their individual needs. Some just need prompting whilst others need individual support. The residents were all very well dressed and groomed. The healthcare records were inspected for four residents. They had all been supported to access the GP, dentist and optician in the last two years. In addition residents attend outpatient appointments for their specialist healthcare needs including psychiatry, psychology and the dietician. All 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 17 healthcare appointments are appropriately recorded and include the outcomes of the appointments. Two residents who have issues with their weight are also supported to have their weight checked on a weekly basis. The medication systems in the home were inspected. The home uses a blister pack system. The medication was appropriately stored and the temperature of the medication cupboard was recorded daily. The medication administration records were completed correctly for all medication including creams. One person has a PRN medication to assist with the side effects of another medication and guidelines need to be prepared on when this should be administered. The medication entering and leaving the home is recorded appropriately on the medication administration record and a separate book. The staff training records were inspected and all the staff who administer medication had an appropriate training certificate to confirm medication training had taken place. 94 Station Road DS0000010531.V357562.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): Standards 22 and 23 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the correct systems are in place should they need to complain and that staff training and procedures are in place to protect them from the risk of being abused. EVIDENCE: The AQAA prepared by the home indicated that the service had received no complaints since the previous inspection. It was observed that the home has a user-friendly complaints procedure as part of the service user guide. Two residents said that they would tell a member of staff if they were worried about anything. The staff training records were inspected for four members of the staff team. These indicated that all of the staff had received training on the protection of vulnerable adults. Norwood has a comprehensive adult protection procedure and the home also has Barnet’s procedure available. Since the last inspection the home has appropriately dealt with an adult protection issue and worked appropriately with other agencies to address this matter. The staff training records also showed that all of the staff whose records were inspected had received training on how to work positively with people who have complex challenging behaviours. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 19 The personal finances were inspected for two residents. Both of them keep their building society books for safe-keeping in the safe in the office and are supported by staff to withdraw cash from their accounts. Both residents also leave cash in the safe in the office. The residents when they withdrew cash from the building society had a record of this cash in their client money record in the home. They then signed when they took cash from their money tin in the home. This allowed the home to have evidence of an audit trail for their money. It was however observed that each resident had two or three building society accounts and this was very confusing. It was recommended that this arrangement was reviewed. 94 Station Road DS0000010531.V357562.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): Standards 24,25,27,28 and 30 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are benefiting from living in a clean and a pleasant environment that is being maintained on an ongoing basis. The home has been personalised to reflect the tastes of the people living in the home. EVIDENCE: The inspector did a tour of the home and looked at some of the bedrooms where the residents gave their permission. The home was clean and tidy throughout. Each person’s bedroom that was seen was well furnished and was homely and personalized. The communal space consists of a large lounge, conservatory and a kitchen with a dining area. These were also well furnished and comfortable. There are adequate 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 21 bathing facilities on each floor. The home has a laundry on the ground floor. All the equipment in the home was observed to be in good working order. Since the last inspection the kitchen has been replaced, parts of the house have been redecorated and the lounge in particular looked very pleasant, new flooring was available in the hallways and utility room and new stair banisters had been provided. The AQAA indicated that the residents were involved in making choices as part of this process. The garden was also well maintained. Whilst there was some further work needed such as repairing broken tiling in the bathrooms and cleaning or replacing some bedroom carpets the inspector could see that this maintenance was taking place on an ongoing basis. 94 Station Road DS0000010531.V357562.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): Standards 32,33,34,35 and 36 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a very stable and experienced team of staff whose performance is maintained with ongoing training. Supervision is not taking place regularly for all staff members. EVIDENCE: The inspector looked at the staff rota. The staff team consists of a manager, deputy manager, senior carer and a team of carers. The manager was on maternity leave at the time of the inspection. The AQAA completed by the home showed that staff turnover is low with no staff changes in the last year. There are no staff vacancies in the home. During the day there are between one and three staff working in the service according to the activities planned. At night there is one sleeping in member of staff. The AQAA showed that all the permanent staff had completed an NVQ at a level 2 or above. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 23 The recruitment checks were inspected for four staff and these were all in place including the application form, CRB disclosure, two references, ID and work permits where needed. All the staff had a copy of their contract of employment in their record and these had been appropriately signed. The record of staff team meetings was inspected and these meetings take place on a monthly basis and discuss a wide range of operational issues. The induction records were inspected for four staff and were not all available in the staff records although previous inspections have recorded that inductions have taken place. The staff training records were inspected for four staff members. All the staff had received comprehensive training but it was noted for staff who had been in post for several years that some of this training would soon need to be updated. It was positive to note that in addition to the mandatory training staff had received additional training on topics such as carrying out risk assessments and person centred planning. The AQAA also explained that staff access training provided by the Local Authority and PCT. Examples of this could be seen in staff training records such as training on diabetes and epilepsy. The staff supervision records were inspected for four staff. All the staff were receiving individual supervision. The home uses a comprehensive supervision format and these were appropriately completed. Three of the staff had not received regular supervision with gaps of four or five months between recorded supervision sessions. The deputy manager acknowledged she had found it hard to keep supervisions up to date. The AQAA completed by the home confirmed that all the staff had completed an appraisal in the last year and copies of these were observed in the staff records. 94 Station Road DS0000010531.V357562.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): Standards 37,38,39 and 42 were inspected. People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that the home is overseen by an experienced acting manager although the permanent manager still needs to complete the registration process. The health and safety of the people living in this home is protected by the appropriate measures. A quality assurance system has been implemented but needs to seek the views of relatives and care professionals. EVIDENCE: At the time of the inspection the manager was on maternity leave and the deputy manager was managing the service with support from a manager of 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 25 another service. The manager had not completed the registration process. It was positive to note that the home was being managed well and that the residents were happy with the service they were receiving. The service did take longer than expected to complete the AQAA and this probably reflects the manager being on leave. There was no other evidence of the service being adversely affected by the manager’s absence. The deputy manager explained that a quality assurance exercise has taken place and this is mainly in the form of a detailed audit. A service user survey has also taken place and copies of the completed surveys were in the resident’s folders. The AQAA explained that regular relative meetings take place and this acts as a useful forum to get their feedback on the service. The AQAA shows that the organisation recognises the need to implement a comprehensive quality assurance system and this needs to seek the views of relatives and care professionals. The home has appropriately reported any serious incidents concerning the service users to the CSCI. The health and safety training records were inspected for four staff. They had all completed all the necessary health and safety training and some will need this training refreshed shortly. The fire safety measures were inspected. The fire appliances and fire alarm had been serviced. Weekly fire alarm and emergency light checks and quarterly drills are recorded as taking place. A fire safety risk assessment is available. The fire safety emergency plan is in place. One resident said that they knew where to go when the fire alarm went off. The self-assessment (AQAA) confirmed that current certificates were available to confirm the maintenance for the electrical installations, portable electrical appliances and gas heating. The current insurance certificate was inspected and was satisfactory. 94 Station Road DS0000010531.V357562.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 3 4 3 5 2 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 4 25 3 26 x 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 4 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 4 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 3 2 x x 3 x 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA5 Regulation 5(1)(b) Requirement The registered person must ensure each resident has a completed contract between themselves and the home. The registered person must ensure that guidelines are in place for residents who take PRN medication. The registered person must ensure the staff receive regular supervision. This requirement is restated. Previous timescale of 31/01/07 was unmet. The registered person must ensure the manager completes the registration application process. This requirement is restated. Previous timescale of 31/01/07 was unmet. The registered person must ensure the home undertakes a quality assurance process that incorporates the views of the relatives and other care professionals associated with the service. Timescale for action 30/04/08 2. YA20 13(2) 31/03/08 3. YA36 18(2) 30/04/08 4. YA37 8(1) 31/05/08 5. YA39 24(1)-(3) 31/07/08 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 28 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. 3. Refer to Standard YA6 YA23 YA35 Good Practice Recommendations The registered person should change the care plans so they are in a user-friendly format. The registered person should support the residents to review the number of building society accounts they have to make their personal finances less complex. The registered person should ensure there is a record of each staff members completed induction in their staff training record. 94 Station Road DS0000010531.V357562.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 94 Station Road DS0000010531.V357562.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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