Care Home: Harrowdene Lodge

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What the care home does well The home provides a suitable stimulating environment for people with learning disabilities and underlying mental health problems. A range of interesting planned and stimulating activities is provided. People using the service can choose if they want to take part in activities and are involved in the planning of new activities. The home is providing person centred care focusing on people’s abilities and support people using the service to achieve their aspiration and dreams. People using the service life in a nicely decorated, clean, stimulating and well maintained environment. The home is keen to improve outcomes for people using the service. The residents were observed to be very relaxed within their home environment. The registered manager is liked and respected by staff and people using the service. What has improved since the last inspection? The home has met all of the ten requirements made during the key inspection in July 2007. Staff no longer cut peoples toenails, guidance and training for people diagnosed with Diabetes are provided, and this ensures people’s heath care needs are met. A medication policy is provided and staff have taken part in medication training, ensuring people are protected when supported around the administration of medication. An up to date policy on death and dying is drawn up and people’s wishes are taken into account. Issues around the environment are addressed; people using the service live in a well maintained and Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 comfortable home. People using the service have opportunities to comment on the care and service provided by the home and quality assurance assessments are undertaken. What the care home could do better: We have made six new requirements to ensure outcomes for people using the service are improved further. Guidelines around the provision of personal care must be drawn up, this ensures new staff is aware of how to meet peoples’ needs and people using the service are supported consistently. Funeral arrangement must be discussed with people using the service and people’s wishes must be recorded. One of the fire doors does not close properly and must be repaired to protected people using the service if there is an outbreak of fire. The main door must be repaired, which ensures people are protected from unauthorised access and exit. The small roof above the entrance must be fixed to prevent accidental injuries. A copy of the annual development plan must be forwarded to the Care Quality Commission (CQC). Key inspection report CARE HOME ADULTS 18-65 Harrowdene Lodge 120 Harrowdene Road Wembley Middlesex HA0 2JF Lead Inspector Andreas Schwarz Key Unannounced Inspection 11th July 2009 09:30 Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 1 This report is a review of the 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. 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 home adults 18-65 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. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harrowdene Lodge Address 120 Harrowdene Road Wembley Middlesex HA0 2JF 020 8908 3504 020 8908 6078 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) Ms Kayte Regina Pinto Ms Kayte Regina Pinto Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 4 21st August 2007 Date of last inspection Brief Description of the Service: 120 Harrowdene Road is small privately run care home providing personal care and accommodation for up to 4 service users with learning disabilities. At the time of the inspection there were three people using the service in the home. The fees are £1740.00 per week. The home is situated in a pleasant residential area. It is an extended semi-detached house in Harrowdene Road, which is off North Wembley High Street. It is easily accessible by British Rail and buses. It is close to shops and to local amenities. There is off-street parking for about 2 cars and there is additional parking on the road. Accommodation for people using the service is provided on 2 floors in single bedrooms. There are two bedrooms, a kitchen, conservatory, a communal lounge and dining areas on the ground floor. There are toilets and bathrooms on each floor. On the first floor there are 2 service users’ bedrooms, the sleepin room for staff and a small office. There are some bushes in the front of the home and there is an extended area at the back of the home with a patio, a lawn and a few trees. Harrowdene Lodge DS0000017502.V376454.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 stars. This means the people who use this service experience good quality outcomes. This inspection is the annual Key inspection and the aim is to look at how well the service is meeting the key National Minimum Standards for Younger Adults. The unannounced inspection consisted of one day and lasted 7 ½ hours. The deputy manager was interviewed and assisted with the inspection. The deputy manager showed us around the home. All three people resident in the home at the time of the inspection were seen. Throughout the inspection the way in which staff communicated with and supported people was observed, as well as how people got on with staff. We also interviewed staff to get their views and comments on the home. We visited the home together with an Expert by Experience; the expert was accompanied by his support worker and spoke to people using the service. Information and comments made to the expert by people using the service are included throughout this report. A wide range of records, including care plans, staff files and health & safety documents, were also looked at. The home’s Annual Quality Assurance Assessment also provided considerable detail about the running of Harrowdene Lodge. What the service does well: What has improved since the last inspection? The home has met all of the ten requirements made during the key inspection in July 2007. Staff no longer cut peoples toenails, guidance and training for people diagnosed with Diabetes are provided, and this ensures people’s heath care needs are met. A medication policy is provided and staff have taken part in medication training, ensuring people are protected when supported around the administration of medication. An up to date policy on death and dying is drawn up and people’s wishes are taken into account. Issues around the environment are addressed; people using the service live in a well maintained and Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 6 comfortable home. People using the service have opportunities to comment on the care and service provided by the home and quality assurance assessments are undertaken. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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. Harrowdene Lodge DS0000017502.V376454.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 Harrowdene Lodge DS0000017502.V376454.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We assessed National Minimum Standards 1 and 2 during this inspection. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed information about the home is available so that people using the service and families know what they can expect from Harrowdene Lodge, the Statement of Purpose and the Service User Guide has been updated. People moving into the home can be confident that their needs and wishes will be fully assessed and an appropriate plan for meeting these needs will be drawn up. As a result their needs are met EVIDENCE: We found a service users guide and statement of purpose in all two files assessed during this inspection. The statement of purpose has been reviewed and detailed information about the home, staffing and care provided is available for prospective people using the service. The new care Quality Commission (CQC) contact details have not been updated yet, which is recommended. The files for two of the people using the service were looked at and indicated that before they moved in a full assessment had been received from Social Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 9 Services. We looked at an assessment done by the home of a person recently been admitted. This assessment was detailed and the person was involved in the assessment process. A care plan had then been drawn up by the home showing how these needs were to be met. Most people have lived at the home for several years and indicated from observation that they were settled at Harrowdene Road. The home informed us in their Annual Quality Assurance Assessment (AQAA): ‘All pre-admission assessments, risk assessments and risk management plans are documented and shared with the prospective resident, their care managers, other proessionals, and important others. Service users will normally have a three month trial period whereby they can decide to terminate their contract at short notice’. People using the service told the expert: “The residents said they were happy in the home and would not want to change anything in the home”. Harrowdene Lodge DS0000017502.V376454.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 6, 7 and 9 during this inspection. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide detailed information so that in general the needs of people using the service are met The staff team at Harrowdene Road is good at finding ways for people using the service to make as many decisions for themselves as possible. People using the service are protected by risk assessments that are comprehensive and indicate clearly how risks to the safety of residents are reduced, whilst still promoting independence. EVIDENCE: We have viewed two care plans during this inspection, people using the service told us that they know about their care plans and signatures confirmed that they have taken part in the review process. The deputy manager informed us Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 11 that the home does not have a key working system. This is due to the attachment people using the service have developed to particular members of staff. Care plans viewed are very detailed and issues important to the person are addressed. These issues include mental and physical health, behaviour management, religious and cultural needs, etc. Each need has been looked at in detail and guidance is drawn up for staff to follow and support people using the service. The home told us in their AQAA: ‘We carry out regular (6 monthly) care plan reviews and needs re-assessments’. People using the service told the expert: “People using the service said staff are nice to them, treat them well and listen to them”. People living at Harrowdene Road are verbal and able to express and choose what they like to do, and where they require support. People using the service told us that staff treat them with respect and listen to their needs. This was observed by staff interacting with people during this inspection. People using the service told us that they can choose to go out, go to restaurants, pub, etc. One person using the service informed us that she does not like to go to day centres, the home is providing in-house and community based activities for this person. We viewed financial records of two people using the service, which have been in order and expenditure and income has been recorded clearly. People’s money can only be accessed by the manager and one member of staff who is responsible for the recording. Finances are audited monthly. We discussed with the deputy manager that people using the service should be encouraged to sign for their expenditure, this should help people to gain a better understanding of their finances and expenditure. The home told us in the AQAA: ‘Service users make choices of their occupational and recreational activities’. Peoples’ files contain a variety of detailed risk assessments in order to ensure their safety, whilst promoting independence wherever possible. These included guidelines for staff when supporting people in the community so that people using the service can get out and about to local shops, whilst identifying ways of reducing any possible dangers to their safety, or the safety of others. Other risk assessments looked at people’s behaviours, risk of falls, etc. Risk assessments are reviewed during person centred planning meetings or if peoples needs have changed. Staff told us that they have read the risk assessments as part of their induction, and demonstrated understanding when interviewed during this inspection. Observations made during this inspection, showed that staff follow risk management guidance to support people using the service safely. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 12 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): This is what people staying in this care home experience: We looked at National Minimum Standards 12, 13, 15, 16 and 17 during this inapection. People using the 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 is good at enabling people using the service to get out and about so that they lead as ordinary a life as possible. Staff supports people using the service to keep in close contact with friends and family, as well as respecting their rights and encouraging them to act responsibly. People using the service enjoy their meals and benefit from being offered a diet that is healthy and reflects their cultural preferences. EVIDENCE: People using the service do not attend structured day centres and have informed us that they don’t want to go to a college at the moment. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 13 The home is providing in-house and community based activities. People told us that they go to the pub, restaurants, cinema, etc. during the day and evening. One person using the service is regularly attending the local church for worship. People using the service informed me that they have been on holiday to Paris this year, which they enjoyed very much. People using the service told the expert: “Residents said they do get out and access activities in he community. They use trains and local buses to get out to places and to the shopping centre”. “Residents enjoy going on holidays and are involved in planning of their holidays”. During the day of this inspection we observed people using the service leave the home with staff for lunch. One person told us that she went to the cinema recently. Receipts assessed showed us that people using the service go regularly to the cinema, pubs, restaurants, shopping, etc. We discussed with the deputy manager that staff should record in daily or activity records, if people using the service have taken part in activities. Staff told us that they have good relationships with their neighbours. Information of outings and activities offered in the local community is displayed on the notice board in the dinning area. Staff employed does not fully reflect the cultural background of people using the service and more effort should be made to take the cultural mix into consideration when employing new staff. People using the service told the expert: “Residents have choices of activities. They go out to the disco and to the cinema”. One person told us that she has a boyfriend, which she is visiting regularly. People using the service have little contact with relatives, but efforts have been made by the home together with residents to improve this. During outings, holidays, etc, people using the service can meet new people or maintain relation ships. People using the service told the expert:” Residents are supported with relationships, as one resident said she has a boyfriend and they do visit and phone each other with staff support”. “Friends and relatives can call and visit when they want”. People using the service informed the expert: “Residents do not have keys to the house or their bedrooms”. Mail is given to people using the service unopened. We observed staff interacting with people using the service professionally. We observed people using the service accessing all areas in the home. Staff and people using the service informed us that they take part in household activities such as emptying the bin or cleaning the dining area. One person using the service told us that she is cleaning her room with support from care staff. The expert made the following observation: “While at the home I witnessed the staff give a letter of one of the residents to open for herself”. All people commented on the quality of food provided in the home. The menu is varied and healthy. The fridge was stocked with food and we observed Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 14 people using the service accessing the kitchen independently to make tea or help themselves to snacks. One of the people living at the home has diabetes, staff demonstrated understanding of this condition and the person told us that she cannot eat certain things due to this condition. People using the service told the expert: “Residents said they love the food, have a choice of what they eat and are involved in menu planning, food shopping and preparation”. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 18, 19, 20 and 21 during this inspection. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are good at meeting the physical and emotional health needs of residents. As a result residents feel more at home and relaxed at Harrowdene Lodge. The residents are fully protected by arrangements regarding medication in the home. People wishes around funeral arrangements are not clearly discussed, but policies and procedures are in place. EVIDENCE: We spoke to people using the service who informed us that they are happy with the personal care provided by staff. Staff demonstrated good understanding of individual personal care needs and showed us that they are aware of people’s likes and dislikes in this area. The home does have no clear personal care guidance for people using the service in place. This has been discussed with the deputy manager and the home is advised to draw up clear Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 16 personal care guidelines on all people using the service. The AQAA confirmed that no cross gender personal care is provided. People using the service told us that they shop for their clothes together with staff. No technical aids are required to meet the needs of people using the service. The home can access specialist health care support through GP referral and Brent Learning Disabilities Team. We observed one person being supported by staff to visit the hospital for a check up. People using the service are registered with their own GP. One of the people living at Harrowdene Lodge has a diagnosis of Diabetes, during discussions with the person it was clear that she is aware of the condition. Staff informed us of receiving information about Diabetes during their induction. People are seen regularly by opticians, dentists and podiatry. The home is recording healthcare appointments in a separate diary. The home is using the NOMAD System and the local pharmacist packs medication weekly. The Medication Administration Sheet (MARS) is in order and had no gaps. The home is providing medication in liquid form; bottles are however not signed, which is recommended. The home receives weekly deliveries of medication. The home does have a medication policy in place, which is compliant with National Minimum Standards. The home has produced a policy on death and dying as required during the previous key inspection. We discussed with the deputy manager if peoples wishes in regards to funeral arrangements has been addressed in care plans. The deputy manager told us that this is still outstanding. We were however ensured that the home will deal with this during the next care plan reviews. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 22 and 23 during this inspection. People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service and their representatives can be confident in the complaints procedures in the home that make sure their concerns are responded to whilst at Harrowdene Lodge. People using the service benefit from safeguarding adults procedures that make sure that they are safe and secure whilst at Harrowdene Lodge. EVIDENCE: The homes complaints policy is available in the Service Users Guide, on the notice board in the dinning room and each of the people using the service rooms. The home did not receive any complaints since the last inspection. People using the service informed us that they would complain to the manager if they were unhappy with anything. The home does not record compliments, which is recommended. People using the service told the expert: “Residents are aware of the complaints procedure and said if they were not happy about anything they would inform the Manager or a member of staff”. The home has a robust Protection of Vulnerable Adults policy in place and local guidelines are available for reference. We have viewed the homes whistle blowing policy, violence and aggression policy and other policies relating to the Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 18 protection of people using the service. Staff spoken to told us of having received adult protection training and records viewed confirmed this. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 24 and 30 during this inspection. People using the service experience and adequate outcome in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance tends to be reactive rather than proactive. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The deputy manager showed us around the home and one person invited us to see her room. The bedroom was nicely decorated and en-suite facilities are available. People using the service informed us that they bought their own pictures and decorated the room with staff support. Harrowdene Lodge is Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 20 newly decorated and meets specifications of the National Minimum Standards. During the tour of the premise some maintenance issues must be addressed and we informed the deputy manager of this. The fire door leading into one of the service users rooms came of the hinges and does not close fully, this must be addressed to ensure people using the service are protected in case of a fire. It is difficult to close the front door and the deputy manager explained to us that the door is broken; we informed the home that this must be addressed. The little roof above the entrance became loose on the left side, which must be repaired. The expert said:” The residents took me around the home and showed me their bedrooms which are furnished with the residents’ choice of décor and personal items”. The home has a separated utility room and a washing machine and dryer is available for people using the service. The home has appropriate infection control policies in place and no offensive odours or smells were noted. The home was clean and people using the service informed us that they help staff with the cleaning of the communal areas. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 32, 34, 35 and 36 during this inspection. People using the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People who use the service report that staff working with them are skilled in their role, and are able to meet their needs. The service ensures that all staff receives relevant training that is focussed on delivering improved outcomes for people using the service. The service has a good recruitment procedure that clearly defines the process to be followed. EVIDENCE: Staff working at the home demonstrated good experience of working with this client group. Staff have been working in the home for a number of years and are knowledgeable about peoples needs, likes and dislikes. People using the service spoke very positive about support staff and one person told us. “I like XXX very much, she is very good”. We have viewed three staff files during this key inspection; two staff have completed their National Vocational Qualification Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 22 in Care, which is above the required 50 . The home does not employ any staff under the age of 18. Care staff told the expert: “The home is well staffed, as one staff member said, and they received good training to support residents with their changing care needs”. All files viewed contained the necessary documents. Staff has undertaken a Criminal Records Bureau check and two references are on file. Staff informed us of having had an interview and pre-employment visit to the home allowing people using the service to comment on applicants. The home provides up to date training and development plan and regular training is provided by the home manager of Eton Avenue another home managed by the organisation. Staff spoken to confirmed of having had an induction and training. Regular refresher training of mandatory training is provided and specialist training can be accessed if required. Staff informed us that they feel supported by the management team and supervisions are done every two month. Records showed us that staff development, performance and relationship with people using the service is discussed during supervisions. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): We looked at National Minimum Standards 37, 39 and 42 during this inspection. People using the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. The manager is person centred in her approach, and leads and supports a staff team who have been recruited and trained. People using the service are aware of safety arrangements and have confidence in the safe working practices of staff. The manager ensures risk assessments are completed and taken into account in planning the care and routines of the home. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager Mrs Kayte Pinto has been registered for the past six years with the Commission for Social Care Inspection (CSCI). Mrs Pinto holds Advanced Management in Care qualification. Staff and people using the service spoke very positive about Mrs Pinto. In addition to this a deputy manager is employed who supports and supervises staff. The registered manager from another care home managed by the organisation is providing professional and clinical support to people living in Harrowdene Road. Staff interviewed spoke very positive about the support provided by the management team. “She (Mrs Pinto) always listens if we have a problem”. Staff meets every third Thursday of the months and records of these meetings have been viewed during this inspection. The home has a quality assurance policy in place. The deputy manager is responsible for monthly quality assurance checks, which look at the environment, people using the service and administrative issues. People using the service meet every two weeks to discuss important issues to the home and the care they receive at Harrowdene Lodge. Records of these meetings are available and it is evident that people using the service participate in these meetings regularly. The deputy manager told us that surveys have been undertaken and a annual development plan is in place. It is required to forward a copy of the annual development plan to the CQC. People using the service told the expert: “Regular meetings are held where residents can say what they want and what activities they would like for the following week(s)”. The fire safety policy has been reviewed in April 2008 and the fire risk assessment has been updated in January 2009. The home is undertaken monthly fire drills and fire points are checked weekly. The fire alarm was last serviced in May 2009 and the fire equipment was last serviced in January 2009. The registered manager is assessing environmental risk monthly. The Landlords Gas Safety Certificate was in order and electrical installations as well as appliances are new. A portable appliance test was undertaken in January 2009. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 2 3 X 3 X X 3 X Version 5.2 Page 26 Harrowdene Lodge DS0000017502.V376454.R01.S.doc 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 YA18 Regulation 12 Requirement The registered person must provide clear written personal care guidance, this ensures people’s likes and dislikes are taken into account and consistency in supporting people is ensured. The home must discuss funeral arrangement with people using the service or their representatives to ensure the wishes and feelings are taken into account and their needs are met. The door leading into one of the service users rooms must be repaired, ensuring people using the service are protected in case of a fire. The front door must be repaired to maintain security and protect people from unauthorised access and exit.. Timescale for action 01/09/09 2. YA21 12(3) 01/09/09 3. YA24 23 15/08/09 4. YA24 23 15/08/09 Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 27 5. YA24 23 The small roof, which became loose on the left side, over the entrance, must be repaired to prevent accidental injuries to people using the service, staff and visitors. The home must forward a copy of the annual development plan to the Care Quality Commission. 15/08/09 6. YA39 24 15/08/09 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. Refer to Standard YA7 Good Practice Recommendations People using the service should be more involved in their finances and be encouraged to sign for expenditures made. Staff should record peoples participation in activities offered by the home more clearly. The home should make more effort in taken the cultural back ground of people using the service into consideration when employing new staff. It is recommended that the possibility of people using the service having a key for the front door and their bedroom with them and assess the risk to service users having a key. The home should record the date of opening liquid medication bottles clearly, ensuring the medicines are not expired when administered to people using the service. The home should try involving an independent advocate DS0000017502.V376454.R01.S.doc Version 5.2 Page 28 2. 3. YA13 YA13 4, YA16 5. YA20 6. YA21 Harrowdene Lodge when addressing funeral arrangements with people using the service. Harrowdene Lodge DS0000017502.V376454.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission London Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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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