Care Home: Edgeworth Crescent 55

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What the care home does well The premises were cheerfully furnished and feels cosy and comfortable. The patio and garden is attractive and had colourful flowers. Residents we met appeared clean, well dressed and well cared for. The home has been able to meet the religious and cultural needs of residents. The home actively ensures that the healthcare needs of residents are attended to. All residents interviewed stated that they were satisfied with the care provided. They indicated that they had been consulted and their preferences and views had been listened to. Residents had been encouraged to be as independent as possible and participate in a wide range of social and therapeutic activities. This ensures that they are stimulated. Residents informed us that they have a say regarding what activities they would like to participate in and where they wish to go for their annual holiday. Staff worked as a team and there is a comprehensive training programme for them. They were knowledgeable regarding the care, cultural observances and preferences of residents. Staff were noted to be attentive and respectful towards residents. Effort had been made to ensure that care documentation is structured and contains up to date care plans and risk assessments. What has improved since the last inspection? The manager of the home is now registered with the CQC. Monthly monitoring visits by the provider have now been sent to the home. The complaints procedure has been updated with new details of the CQC. What the care home could do better: The medication policy and procedure must be reviewed and updated and this must be done yearly. This is to ensure the safety of service users. The adult protection procedure must be updated and contain guidance on when a medical examination is needed, when the Police are to be notified, suspension of any staff member implicated and reporting of staff involved to the Independent safeguarding Authority. This is to ensure the protection of residents. The fire authorities or LFEPA must be consulted as to whether the home`s fire evacuation plan can be carried out safely with only one staff on duty during the night shift. An appropriate decision regarding staffing levels must be made following the outcome. This is to ensure the safety of all at the home. Key inspection report Care homes for adults (18-65 years) Name: Address: Edgeworth Crescent 55 Edgeworth Crescent 55 Hendon London NW4 4HA     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Daniel Lim     Date: 2 0 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 32 Information about the care home Name of care home: Address: Edgeworth Crescent 55 Edgeworth Crescent 55 Hendon London NW4 4HA 02082034707 02082034707 edgeworth@norwood.org.uk bucketsandspades@norwood.org.uk Norwood Ravenswood Ltd T/A Norwood Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Arlene Helena Pentel Type of registration: Number of places registered: care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability physical disability Additional conditions: Limited to 6 adults of either gender with a learning disability (LD). Specific service user over 65 years One specific service user who is currently resident in the home and is over 65 years of age can reside in this home. This condition will need to be reviewed when s/he vacates the home. Specific Service user with a Physical Disability One specific service user who is currently resident in the home and also has a physical disability can reside in this home. This condition will need to be reviewed when s/he vacates the home. Date of last inspection Brief description of the care home Edgeworth Crescent is a small care home accommodating six younger adults with mild to moderate learning disabilities. Some of the people living at the home also need support with their mental health. The home is owned and run by Norwood, a Jewish Care Homes for Adults (18-65 years) Page 4 of 32 Over 65 1 0 6 1 Brief description of the care home Charity that provides a service to children, adults and their families. The charity also runs other care homes in London. The homes stated objective is to provide safe and secure twenty-four hour care in a homely environment to adult males and females with learning disabilities. The house was built in the 1920s as a private dwelling. It was converted into a residential care home which opened in 1995. The entrance hall on the ground floor leads to a large lounge. On this floor is also located the laundry room, a small reception room and a large bright kitchen/diner. There is one bedroom with en-suite facilities on the ground floor. On the first floor there are five bedrooms, one with en-suite facilities. There is also a communal bathroom with a toilet and a separate shower room with a toilet. The office is downstairs. The previous office which is upstairs is now used as a second lounge and a sleep-in room at night. The home has an attractive, secluded back garden, which is set on two levels. There is a new patio with seating. At the time of the inspection there were six people living in the home. Details of fees charged by the home can be obtained from the manager. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Care Homes for Adults (18-65 years) Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is THREE STAR. This means the people who use this service experience EXCELLENT quality outcomes. This inspection was carried out by Daniel Lim, inspector on 20 April 2010 and took a total of five hours to complete. We were assisted by the registered manager, Arlene Pentel. Four residents who were in the home during this inspection were interviewed. Four CQC completed surveys were received from residents, three from staff and one from a healthcare professional. Statutory records were examined. These included three residents case records, the maintenance records, accident and incident records, financial records, complaints records and fire records of the home. The premises including residents bedrooms, communal bathrooms, laundry, kitchen, Care Homes for Adults (18-65 years) Page 6 of 32 garden and communal areas were inspected. Two care staff were interviewed regarding the care of residents and other areas associated with their work. They were noted to be knowledgeable regarding their roles and responsibilities. Staff records, including evidence of CRB disclosures, references, supervision and training records were examined. In addition, the minutes of residents and staff meetings were examined. These indicated that residents and staff had been consulted and informed of changes affecting the running of the home. The completed Annual Quality Assurance Assessment form or AQAA was received by us. Information provided in the assessment was used for this inspection. Care Homes for Adults (18-65 years) Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Adults (18-65 years) Page 8 of 32 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken by the manager. Admissions only take place if the service is confident that the needs of people to be admitted can be met. This ensures that the admissions to the home are appropriate. Evidence: The AQAA states : We provide a warm, caring home for the residents to live in and enable the residents to be independent in all aspects of their lives. We continually review our working practices and procedures so that we are meeting the needs of the residents. Residents Personal Care Plans shows progression and how the residents spend their time and make choices. No new resident had been admitted into the home since the last inspection. Three case records of residents were examined. these contained appropriate and Care Homes for Adults (18-65 years) Page 11 of 32 Evidence: comprehensive assessments. Comments made by residents regarding the home included the following : They take good care of us. I am happy here. The house has got better and better. I am satisfied. Care Homes for Adults (18-65 years) Page 12 of 32 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service recognizes the right of individuals to take control of their lives there is evidence that residents are supported and involved in decision making about the home. Residents are consulted on how the service runs and activities they wish to participate. Each individual has a care plan, and residents are involved in the development of their care plans. The care plans include preferences and appropriate risk assessments. Evidence: The AQAA states: The residents at 55 Edgeworth Crescent have full independence and choice in relation to lifestyle choices. They all lead a full, active and healthy lifestyle with varying degrees of independence and with all emotional and social needs being met by the team of staff. These can all be evidenced via the residents, Personal Care Plans and daily logs. Care Homes for Adults (18-65 years) Page 13 of 32 Evidence: The three residents case records examined contained comprehensive and appropriate care plans, assessments and details of reviews carried out. The preferences of residents had been documented and staff interviewed were aware of them. There was documented evidence that residents had been encouraged to be as independent as possible. Risks assessments had been prepared for residents. They were noted to be comprehensive and up to date. Staff were aware of action to be taken to minimise risk. There was documented evidence that the care of residents had been reviewed. The minutes of these reviews, including reviews done by health and social services professionals were kept in the case records and available for inspection. We were able to interview residents regarding their needs and choices. They indicated that staff had responded to their preferences and they were provided with support in pursuing various activities and interests. We were also informed that they had been consulted and there were weekly meetings where they could discuss their concerns and also put forward suggestions. Care Homes for Adults (18-65 years) Page 14 of 32 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had sought the views of residents and considered their varied interests when planning their daily routines. Links to specialist support are facilitated when needed. Residents have opportunity to develop skills and are encouraged to participate in a wide range of activities within the community. The arrangements for the provision of meals take into account the preferences of residents and their dietary needs. Evidence: The AQAA states: All residents have key workers. Staff are able to assist the residents to identify their wishes, choice and goals. Staff will respect residents views and will encourage residents to participate in the lifestyle of their choice. Two of the residents have paid jobs and we encourage and enable them to achieve this. One of our residents job has Care Homes for Adults (18-65 years) Page 15 of 32 Evidence: been terminated and we are working with the Job Coach at Norwood to find new employment. All the residents have different hobbies and interests. They all have been involved in choosing their courses and activities. The case records of residents contained care plans detailing social and educational activities that residents have been involved in. We note that the home has a weekly programme of varied activities for residents. These included cooking, shopping, football matches and going to the day centre and a social club called Links. We were informed by the manager that residents had been involved in household chores such as cleaning and tidying their bedrooms and doing their washing. Residents also stated that they had contact with their relatives. The religious observances of residents had been encouraged. We were informed by residents that all food served were kosher and they have celebrated their Jewish festivals and special days at the home. The manager informed us that the local Rabbi visits the home regularly. The kitchen was inspected and found to be well equipped and clean. Daily recorded temperatures of the fridge and freezer had been kept. These were on the whole, satisfactory. A fire blanket and first aid box were in place. We were informed by the manager that residents decide on the daily menus. Residents interviewed stated that they were satisfied with the meals provided. Care Homes for Adults (18-65 years) Page 16 of 32 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have access to healthcare services in the local community. There is evidence in the case records that healthcare needs are monitored and appropriate intervention taken. The arrangements for the administration of medication were specifically detailed in the care plans. People who use services were encouraged to retain control and responsibility for medication. Improvements are however, needed in the arrangements for the administration of medication. Evidence: The AQAA states : All residents have a health action plan that was completed by the residents, or with support given by staff. All residents are registered with a GP, optician, dentist and chiropodist. Those with further needs are regularly seen by a specialist. We keep records of all appointments and outcomes. All documented and any relevant information is passed on to the staff team. All residents medication are now stored in lockable cabinets in their bedrooms. Medication is now administered in the privacy of their bedrooms. We are encouraging and enabling two residents to self medicate. Care Homes for Adults (18-65 years) Page 17 of 32 Evidence: We noted that residents we met were cleanly dressed and appeared well cared for. We interviewed those who were present during the inspection. They were able to express their views freely and informed us that they were satisfied with the care provided. They indicated that they had been in contact with healthcare professionals and could see a doctor if they wanted to. The case records contained evidence that they had been actively supported in attending healthcare appointments with professionals involved. They further indicated that staff had treated them with respect and dignity and they have received the medical care they needed. This was also confirmed in the completed surveys received. Comments made by them included the following: I get my medication each day. Staff understand my needs. I can see the doctor if I am sick. I can see the dentist when I want to. We examined a sample of three residents case records. These were structured and each contained a photo of the resident, appropriate care plans and assessments. Plans of care had been signed by residents or their representatives. This is good practice and ensures that they are made aware of their care arrangements. These were reviewed six monthly. Risk assessments together with plans for minimising risks were in place. One to one sessions with residents had been carried out. We were also informed that the organisations own dietitian visits the home regularly to discuss dietary matters affecting residents. We examined the care and plans of a resident who had a history of recent behavioural problems. The care plans were appropriate and contained a risk management plan for this resident. There was evidence that staff had made effort to assist this resident and the care had been reviewed with professionals involved. We however, were informed that staff continued to have difficulty in caring for this resident and the manager informed us that this resident was not appropriately placed and was at risk. In addition, other residents had complained about this residents behaviour. We discussed the need for the manager to again communicate their concerns to the purchasing authority and specify a deadline for transfer to a more appropriate accommodation. Soon after this inspection, we were informed that a deadline had been given to the purchasing authority for this resident to be transferred. Care Homes for Adults (18-65 years) Page 18 of 32 Evidence: We examined the arrangements for the administration of medication. Medication received had been recorded. Medication was stored in a locked cabinet which is secured to the wall. The temperature of the rooms where medication was stored had been recorded daily and were satisfactory. The Medication Administration Record Charts were examined. We note that these had been signed to indicate when medication had been administered. No unexplained gaps were noted in the charts examined. There is a weekly audit of medication which is good practice. We were informed by the manager that an external audit had been carried out recently and they were still awaiting the audit report. There is a record of medication sent back to pharmacy and this is appropriately signed.. The home has a medication policy with an accompanying procedure. The policy and procedure examined, had not been updated within the past year. This was discussed with the manager who agreed to ensure that the policy and procedure are updated. We were informed soon after the inspection that a working party had been set up to review the policy and procedure and the new policy is expected at the end of May 2010. Care Homes for Adults (18-65 years) Page 19 of 32 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an open culture that allows residents to express their views and concerns in a safe environment. This ensures that residents are well treated and protected from abuse. The arrangements for responding to complaints and for adult protection were on the whole, satisfactory. However, further improvements are needed to ensure that the adult protection procedure is up to date. Evidence: The AQAA states: We welcome complaints and use them as positive feedback. If we receive a complaint we will follow policy and procedure to ensure that it is dealt with swiftly. We have clear abuse and bullying policies alongside other relevant policies. All staff have had training in this area and are updated when required. Three residents have made a complaint this year with regards to other residents. The complaint was passed to the service manager who took the complaint seriously. Residents informed us that they had been well cared for and no complaints were made by them during the interviews. They informed us that they knew who to go to if they wanted to complain. The complaints record was examined by us. Complaints were recorded and kept in a folder. We note that the procedure on display in the folder did not contain the current details of The CQC. We examined two recent complaints made. Care Homes for Adults (18-65 years) Page 20 of 32 Evidence: One had a date when it was responded to. However, no details of the response were available for inspection. The manager said it had been satisfactorily dealt with by the area manager. The second complaint had been responded to by a senior manager of the organisation. However, the date recorded was not within the timescale of 28 days. This was brought to the attention of the manager. Complaints made must be responded to and details must be provided. This ensures that residents are well cared for. Soon after the inspection the manager informed us that the new details and address of CQC are now in the Complaints File and she had amended the file to make the procedure easier to follow. In addition, she stated that there is now a copy of the response for one of the complaints mentioned, which was responded to within the required 28 days. The other complaint had received a reply within the required 28 days, as the senior manager concerned was not able to visit the home within that time span, the formal response was late. The protection of vulnerable adults was discussed with staff. They were aware of the types of abuse which may be encountered and the need to bring it to the attention of their manager or Social Services. They informed us that staff training had been provided. This was also confirmed by the manager. The agency has an adult protection policy and procedure. The local authority guidelines were also available. We however, note that the adult protection procedure had not been updated and was not sufficiently comprehensive as it did not contain guidance on when a medical examination is need and when the Police are to be notified. It did not contain guidance on suspension of any staff member implicated or reporting of staff involved to the Independent safeguarding Authority. This is required to ensure the protection of residents. We were informed soon after the inspection that a new policy would soon be sent to the home. Care Homes for Adults (18-65 years) Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that is aimed at the specific needs of the people who live there. The home was clean, well equipped and furnished to a high standard, therefore providing a nice environment to live in. Residents have been encouraged to personalise their bedrooms and they have a say in the way the home is furnished. Evidence: The AQAA states : The home is homely, with beautiful fixtures and fittings all chosen by the residents. The garden patio has been replaced and residents will be able to use the garden again this summer. Families and friends of the residents are always welcomed. Resident chose to purchase a Karaoke machine and a Wii. New patio, lounge suite, dining table and chairs. During our inspection of the premises, we noted that bedrooms had been personalised by residents with their own pictures and ornaments. The bedrooms were well furnished. All the residents we spoke to said they were satisfied with the accommodation provided. The bedroom of one resident did not have any chairs. The Care Homes for Adults (18-65 years) Page 22 of 32 Evidence: resident informed us that he did not want them in his bedroom. The main lounge had new armchairs and appeared cosy. It overlooks the garden. There is an aquarium in one corner. The manager informed us that residents like this feature and another aquarium may be purchased in the near future. There is a computer in the small lounge on the ground floor. The manager informed us that this is for the use of residents and it has internet access. The completed CQC surveys received indicated that the home was always fresh and clean. No offensive odours were detected in the home. The required safety inspections to the electrical installation, gas and portable appliances had been carried out. The laundry room was inspected and noted to be well equipped. Linen which had been laundered were noted to be clean, neatly folded and stored in cupboard. The gardens were well maintained. We note that an area had been allocated to growing vegetables for the home. Care Homes for Adults (18-65 years) Page 23 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a good recruitment procedure that is followed in practice. The manager recognizes the importance of training and tries to deliver a programme that meets statutory requirements. Residents and their representatives are on the whole satisfied with the staffing arrangements. Evidence: The AQAA states: We have a recruitment procedure to ensure all staff meet the legal requirement and have high personal quality. We all focuse on our primary goal of enhacing the lives of those in our care. Adopting a flexible approach to our rota system to meet the individual needs of the residents. Ensure that all Mandatory training is up to date and encourage further training to ensure that staff will develop to their fullest potential. All staff members attend training and have gained NVQ 2,3,4. Selection and recruitment follow Norwoods policies and procedures. Inclusive recruitment enables our residents to have choice when staff are employed. Staff at 55 Edgeworth work as an established team. Supervision,appraisal and training records are all evident. Two staff who were on duty were interviewed on a range of topics associated with their work. They were noted to be knowledgeable regarding their roles and Care Homes for Adults (18-65 years) Page 24 of 32 Evidence: responsibilities. There was documented evidence in the staff records to indicate that staff had been provided with essential training relevant to their area of work. Staff stated that there was a good team spirit and they worked well together. The records of three staff were examined. These indicated that the required recruitment standards and procedures such as obtaining satisfactory CRB disclosures and references had been followed. There was documented evidence of regular formal staff supervision. This was also confirmed by staff interviewed. The supervision notes indicated that staff had opportunity to discuss any work related issues related to the care of residents and their training. We discussed the daily duty rota. We note that in addition to the manager and deputy manager, there was normally a minimum of two care staff on duty during the day shifts and one care staff on sleep-in duty during the night shifts. Staff and residents indicated that this staffing level was adequate. One residents stated that she would like to have more staff. The issue of equalities and diversity was discussed with staff. Staff demonstrated an understanding of the need to treat all residents sensitively and with respect. They were also knowledgeable regarding the Jewish culture and had ensured that residents were able to continue with their religious practices and observances. The manager indicated that all staff had attended training on Jewish culture. Care Homes for Adults (18-65 years) Page 25 of 32 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is user focused and take account of equality and diversity issues. It works in partnership with residents and their representatives. Staff supervision is in place. The manager is aware of areas that are deficient and is working to improve the care and management of the home. Further clarification is needed regarding the adequacy of the fire evacuation plans. Evidence: The AQAA states : The homes manager has been in post for 18 months, and holds an NVQ Level 4 Registered Managers Award. The manager leads by example and is a role model at all times. The home is very person centred. As a staff team we are fully aware that each resident is an individual. The service encourages residents to be independent in all areas of their lives. This is being achieved by lifelong learning. We continually review our working practices and procedures so that we are meeting the needs of the residents. Care Homes for Adults (18-65 years) Page 26 of 32 Evidence: We were provided with evidence that residents and staff had been consulted regarding the management of the home. The minutes of these meetings were available for inspection. There was evidence that suggestions made by residents had been responded to. These included suggestions regarding meals provided and holiday destinations. Residents and staff who were interviewed indicated that they were happy with the overall management of the home. Residents stated that they were well cared for and had been treated with respect. Staff indicated that there is a good team spirit. The manager was noted to be knowledgeable regarding her role and responsibilities. She stated that she has extensive experience in the care field. The home has a current and appropriate certificate of insurance. The financial records of three residents were examined. Receipts were obtained for transactions made on behalf of residents. Signatures of residents and staff were evident for transactions made. The fire logbook was examined. The weekly fire alarm tests, emergency lighting checks and fire drills had been carried out and documented. There is an updated fire risk assessment. The required health and safety inspections on the portable appliances, gas and electrical installations had been carried out. We examined the fire evacuation plan during the night shift. This indicated that only one staff was on sleep-in duty during the night. We discussed the need to have two staff during the night to ensure that residents can be evacuated safely. The manager agreed to consult with the fire authorities or LFEPA as to whether the evacuation plan can be carried out safely with only one night staff in the home. We were informed soon after the inspection that the manager had spoken to LFEPA and forwarded the fire evacuation plan to them. She had also arranged with the fire contractor to visit the home the following week to check the evacuation plan and to carry out a full assessment concerning fire risk. During the inspection, we were not provided with a Mental Capacity Act policy and procedure and we did not view evidence that all staff had been provided training in this area. The manager stated that she had attended the full training. To ensure that staff are fully informed and residents rights are protected, training in this area is needed. The home must also have the required policy and procedure is needed. Soon after the inspection, the manager informed us that the policy and procedure have all been downloaded and printed. In addition, she stated that the staff team had also received some of the training previously and there had been discussions in a staff meeting as recorded in the minutes. Care Homes for Adults (18-65 years) Page 27 of 32 Evidence: The issue of quality assurance and monitoring systems was discussed with the manager. We were informed that consumer surveys were being carried out and this included surveys regarding holidays arranged, accommodation and other activities. In the last key inspection report, the provider was required to ensure that monthly monitoring reports are sent to the home in a timely manner to maximise the quality of the service provided to residents. We were not able to view any of these reports during the inspection. The manager informed us that these had been carried out by the area manager but she was unaware they had been sent to the home recently. This requirement must be fully complied with. This is needed to ensure that staff are fully informed of any action needed to improve the service. We were informed soon after the inspection that the home now have the copies of these reports on file. Care Homes for Adults (18-65 years) Page 28 of 32 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The medication policy and 05/07/2010 procedure must be reviewed each year. This is to ensure that staff are provided with the necessary up to date guidance and for the safety of service users. 2 23 13 The adult protection 17/06/2010 procedure must be updated each year. The updated policy should contain guidance on when a medical examination is need, when the Police are to be notified, suspension of any staff member implicated and reporting of staff involved to the Independent safeguarding Authority. This is to ensure the protection of residents. Care Homes for Adults (18-65 years) Page 30 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 42 23 The fire authorities or LFEPA 04/06/2010 must be consulted and an appropriate decision made regarding night stafing levels . This is to ensure the safety of all at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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