Care Home: Roland Care Home (Compton Road)

What the care home does well The staff at Compton Road are knowledgeable with regard to the needs of the people living in the home. There is an experienced registered manager leading a stable staff team that take a proactive approach. This improves the lives of the people living in the home and they benefit from a well run home. People`s needs are assessed thoroughly prior to admission into the home. This ensures that the home can meet people`s individual needs. People have clear up-to date care plans and their assessed and changing needs are reflected in their care plan. This ensures that people`s changing needs can be met and people can be supported in a consistent professional way by the staff team. People living in the home make clear decisions about their lives were possible and their involvement in the home is fully promoted. This makes them feel empowered. People living in the home undertake a range of activities both in the local community and within their own home, which improves their social inclusion and independence.People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. People are offered a healthy varied diet and their cultural wishes and preferences are respected. This further empowers them as they are treated as individuals. People`s physical and emotional health care needs are met. This safeguards their health and wellbeing. People are protected from potential abuse as clear adult protection procedures are in place, which is supported by a robust recruitment procedure. The home has a clear complaints procedure that is regularly reviewed by the organisation. The rights of people to complain is taken seriously by the organisation as people`s views are listened to and acted upon. A qualified skilled stable staff team support the people living in the home. This ensures that people`s individual needs can be met. There is an established quality assurance system in place that incorporates the views of the people living in the home. There are effective health and safety procedures in place to protect the people living in the home. What has improved since the last inspection? An identified persons medication and the identified frequency of the application of the medication that the person would allow the medication to be applied is now resolved. What the care home could do better: The registered manager has agreed to develop a risk assessment in relation to the management of an identified persons own finances as it is felt they have progressed to the point were the responsibility they undertake in this area canbe further developed. The manager is also going to undertake a risk assessment in relation to one identified who may make false allegations particularly when clear boundaries are maintained by the staff team. CARE HOME ADULTS 18-65 Roland Care Home (Compton Road) 4 Compton Road London N21 3NX Lead Inspector Wendy Heal Key Unannounced Inspection 8th September 2008 9:30 Roland Care Home (Compton Road) DS0000010635.V371322.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 Roland Care Home (Compton Road) DS0000010635.V371322.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. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Roland Care Home (Compton Road) Address 4 Compton Road London N21 3NX 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 8360 3713 020 8211 4539 amalroland@aol.com Mrs Nilmarnie Gaithri Ranetunge Mr Dushmanthe Srikanthe Ranetunge Amal B.D. Nawarathna Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. You may only accommodate people in the two bedrooms located in the loft extension When they have been subject to an assessment by a competent person representing the person and nominated by the placing agency. In the case of a person who is self funding, the assessment must be undertaken by a competent person who is independent of the home e.g. Consultant Psychiatrist, C.P.N., Care Manager. This assessment must state clearly that the person is able to escape from their room in the event of a fire, without the assistance of staff. A copy of this assessment must be retained in the home and be available for inspection. Any such assessments held by the home, must be subject to regular external review in accordance with the changing needs, abilities or condition of the person. 20th September 2006 Date of last inspection Brief Description of the Service: 4 Compton Road is a home registered to provide accommodation and personal care for a maximum of seven younger adults with mental disorders. The home was first registered on 4th April 2000 and is one of four residential care homes belonging to Roland Homes, a company owned by Mr and Mrs Ranetunge. The home is a two-storey terrace house with a loft extension. On the ground floor, there are two bedrooms, a toilet, a kitchen and a lounge/dining room. On the first floor, there are three bedrooms and a toilet/ accessible shower. There are two bedrooms, an office and a bathroom on the second floor (loft extension). There is a small parking space at the front of the building and a garden at the back. The garden is paved and accessible to people living in the home. The home is located in a residential area near to Winchmore Hill. There is a bus service passing near the house. Local shops and other community facilities are within a short walking distance of the home. The home currently charges from £675 per week depending on the assessed needs of the person. Information, including the contents of CSCI reports is available to stakeholders and a copy of the latest CSCI report is kept in the home’s lounge. The aim of the home is to provide high quality care and support to people and to promote and maximise their independent living skills. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The rating for this service is excellent (3 stars) this means that people who use the service receive good outcomes. This was an unannounced inspection and took place as part of the inspection process. Compliance was checked against key standards and took approximately 9 hours. We undertook a tour of the building spoke with the people who live in the home and members of the staff team. We gained further information from the Annual Quality Assurance Assessment form and an inspection of the documents kept in the home. This included care plans and health and safety documentation. The provider Mrs Ranetunge, the registered manager and deputy manager offered their assistance throughout the period of the inspection. We would like to thank the people who use the service and the management team for their openness and participation. What the service does well: The staff at Compton Road are knowledgeable with regard to the needs of the people living in the home. There is an experienced registered manager leading a stable staff team that take a proactive approach. This improves the lives of the people living in the home and they benefit from a well run home. People’s needs are assessed thoroughly prior to admission into the home. This ensures that the home can meet people’s individual needs. People have clear up-to date care plans and their assessed and changing needs are reflected in their care plan. This ensures that people’s changing needs can be met and people can be supported in a consistent professional way by the staff team. People living in the home make clear decisions about their lives were possible and their involvement in the home is fully promoted. This makes them feel empowered. People living in the home undertake a range of activities both in the local community and within their own home, which improves their social inclusion and independence. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 6 People are encouraged to have appropriate relationships and maintain contact with family and friends, which promotes their emotional wellbeing. People are offered a healthy varied diet and their cultural wishes and preferences are respected. This further empowers them as they are treated as individuals. People’s physical and emotional health care needs are met. This safeguards their health and wellbeing. People are protected from potential abuse as clear adult protection procedures are in place, which is supported by a robust recruitment procedure. The home has a clear complaints procedure that is regularly reviewed by the organisation. The rights of people to complain is taken seriously by the organisation as people’s views are listened to and acted upon. A qualified skilled stable staff team support the people living in the home. This ensures that people’s individual needs can be met. There is an established quality assurance system in place that incorporates the views of the people living in the home. There are effective health and safety procedures in place to protect the people living in the home. What has improved since the last inspection? What they could do better: The registered manager has agreed to develop a risk assessment in relation to the management of an identified persons own finances as it is felt they have progressed to the point were the responsibility they undertake in this area can Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 7 be further developed. The manager is also going to undertake a risk assessment in relation to one identified who may make false allegations particularly when clear boundaries are maintained by the staff team. 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. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience an excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. People moving into the home can be extremely confident that their individual needs will be thoroughly assessed and discussed with them prior to moving into the home. This ensures that their individual needs can be fully met. EVIDENCE: Two new people had been admitted to the home since the last key inspection. As a result of one person progressing to the point were they were able to take the positive steps of returning home to their family. The registered manager of the home confirmed that one other person had moved on because the home identified the person’s needs had changed and they required nursing care. Two people’s files were inspected at random. The files contained a range of very detailed assessment information. The homes manager had gone to great lengths to obtain detailed information in relation to the individual people that had moved into the home. This included documented information from Barnet and Enfield trust. The manager had ensured that five separates visits were undertaken to obtain as much information as possible with regard to one individual person and their specific needs. The information recorded included the observations and contact made with the person by members of the staff team during various meetings and during the trial visits. This ensures that the whole staff team are involved with in the assessment process at an early Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 10 stage. This assists to promote a positive introduction to the service for the person concerned. This provides the individual person with a sense of security and assists to make the experience a positive one for them. This information would then contribute to the completion of the person’s individual assessment. The registered manager had been present and obtained information from ward rounds and CPA meetings, and family contacts. There was also clear risk assessment information available on the file and clear contingency plans. This assists to ensure that the whole process of the assessment and introduction of the person to the service is as professional and as thorough as possible. The inspector was confident by the information documented and available on the file that any new person moving into the home would only be admitted to the home after a full assessment of need and a trial period, which would not be rushed but undertaken at the person’s individual pace. This would ensure that the home could meet the person’s needs. One person spoken with in private said, “I was happy with the way I was supported when I moved into the home.” Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, People who use the service experience an excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. People’s assessed and changing needs and personal goals are reflected in their individual care plans, which ensure that people’s individual needs can be met. People do make decisions about their daily lives, which promotes their independence and empowers them. People are supported to take risks as part of an independent lifestyle. Further risk assessments need to be developed in relation to finance and making false allegations to ensure that all potential risks are identified. EVIDENCE: Three people’s care plans were inspected. They were clear to read. The care plans identify people’s basic information such as date of admission, date of birth, their chosen religion, next of kin, social worker, key worker and General practioner. There is also a photograph of the person on their individual file. The care plans identify various areas such as self-care and appearance, domestic skills, personal relationships, leisure and recreation, community participation, mobility, communication, physical and mental health, daily living skills, social skills, work and education. The care plans inspected were linked to and Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 12 reflected the assessed needs of the individual people. The plans identify people’s individual needs and there are identified goals that need to be achieved to ensure their individual needs are met. One identified person has a number of goals identified. One of these is to live independently and undertake activities without staff involvement. The staff team takes the goals of individual people seriously; this assists people to develop on an individual basis and seems to be very important to the whole staff team. An example to evidence this is one person is given an agreed amount of money each week to obtain his or her own food for meal preparation. The person is encouraged to buy only the items listed on the shopping list, which the staff assist the person to complete. The information in the care plan confirms that the person should be encouraged to prepare fresh food rather than convenience foods. This assists to promote their health and wellbeing. The person concerned is encouraged to use the local shops, and local transport and is also making use of the dial a ride service, which promotes their inclusion within their community. Clear guidance is given to staff on how to assist people to achieve their goals. If the person concerned buys many items, which are not listed on the shopping list staff are requested to encourage the person to take the items back to the shop to exchange them for the necessary items. This ensures that the person is supported to learn the necessary skills to assist them to gain their independence. Another identified person who is of Hindu religion has specific information identified in their care plan in relation to their cultural needs like the wish to listen to Hindu music watch Gujarati films, attend the Hindu temple. The registered manager informed the inspector that the person’s key worker is of Gujarati origin. This ensures the persons cultural needs are promoted and respected. This is a good example of how the person’s care is being carried out in line with their needs wishes and preferences. The interaction between the people living in the home and the people working in the home was observed. The inspector witness particular situations were people were making decisions for themselves such as the wish expressed by one person to stop or cut down on the number of cigarettes that they smoke. The identified person was observed as being very at ease with the staff, which in the inspector’s opinion provided him with the confidence to express his wishes. These were appropriately acknowledged in a positive way and the opportunity was taken to identify the difficulties this may cause for this person and the need for there to be an agreement in place regarding this identified goal. The person was provided with the opportunity to discuss the matter further with senior staff members. One person was being supported to undertake an activity with staff in the community on the day of the inspection, which they were eager to undertake and with this in mind the inspector only spoke with the person for a short while but they confirmed they were “very happy in the home.” Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 13 People are encouraged to manage their own finances as much as possible. The home act as facilitators and assist people to open and operate individual bank accounts and records of bank statements were seen on the files inspected. One identified person who had independently withdrawn money from the bank on two separate occasions but had only given the receipt to the manager of the home for one of the transactions. The manager had identified this situation by the fact that the bank statements had been checked by himself which is part of the clear financial procedures the home follows. After a discussion with the senior management team it was agreed buy all parties that this issue would be risk assessed and a discussion would take place with the identified persons social worker. It would be suggested that the person take responsibility for her finances including the responsibility of their bankcard. This person has in the past stated that they will make false allegations against staff when situations arise were clear professional boundaries have to be adhered to. Staff have discussed this matter with the person concerned and the registered manager has confirmed that the person has acknowledged this is wrong. After further discussion it was agreed that this area also needed to be risk assessed. All of the times when the person states they will make a false allegation are going to be recorded and the social worker is to be made aware of this. This will ensure that clear records are available if a professional meeting or any future action needs to be taken. On the day of the inspection the manager had already agreed a time to meet with the persons social worker to discuss these issues. The risk assessments to show potential risks for individual people are being reviewed and kept up to date. This minimises the potential risks to the people living and working in the home. The risk assessments, which were seen on the individual people’s files that were inspected covered areas such as fire related to people smoking, hot water, risk of self injury self, self-neglect, risk to property, finances, risks identified related to current mental health and the need to constantly access the current situation, and risks when out in the community were also seen. The risk assessments specify the identified risks and confirmed the advantages of minimising the risks for the individual people. The individuals themselves are involved the risk assessment process. A list to indicate that staff had read the current risk assessment was seen on the individual files inspected. This ensures that staff are fully informed with regard to the risks associated with the people living in the home, which promotes their health and safety. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 14 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): 11,12,13,15,16,17, People who use the service experience an Excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. People’s personal development is promoted and encouraged. People undertake appropriate activities both in and outside the home, which ensures their cultural needs and preferences are met. People are actively encouraged to maintain their relationships. This promotes their emotional wellbeing. People rights are promoted and respected within their daily lives, which makes them feel valued. People are supported to choose healthy nutritious meals, which benefit their health and wellbeing. EVIDENCE: People living in the home go to the external day centre on average two days per week. People have their own activity plan for the week, which has been discussed and agreed with them. A range of activities are undertaken and include a women’s only group, swimming sessions, art/craft work, going to the library and going to the Gym. This promotes peoples social inclusion and makes them feel valued. The activity plans evidence a range of opportunities to promote and develop people’s independence. These include helping with the Sunday roast, changing their own bedding, cleaning their own toilet, Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 15 bath/shower room, shopping with staff supervision, or shopping independently. On the day of the inspector the inspector spoke with one individual who completes a shopping list of food items to be brought, then shops for them to enable the person to cook and prepare their own meals. The person concerned confirmed that these tasks are undertaken. The person went onto say “before I moved into the home I could not cook but now I am a good cook.” The person concerned was very pleased with what they had achieved. The staff team spoke in a very warm affectionate way with regard to this individual person’s cooking abilities. Two other people living in the home also cook for themselves. The majority of the people living in the home travel independently and are fully involved in the local community. Those people spoken with confirmed they had freedom passes to access public transport. Staff do assist those people who may need support in the community if this is what the person needs to ensure they have the opportunity to develop as an individual and achieve their identified goals. People’s religious rights are respected as some of the people living in the home and are supported by staff to attend the temple. Other people choose to attend church on a Sunday, which was confirmed during a discussion with one of the people living in the home. This empowers them and ensures their rights are respected. A number of activities are provided within the home people can watch the television. The registered manager confirmed that the television in the home is able to receive channels where Gujarati and Hindu are spoken. One person confirmed People could take part in a movie evening in the lounge and play board games. This ensures that there are opportunities for them to be stimulated at home to prevent them becoming bored and allows them to socialise together. The people living in the home have contact with their family and friends. On the day of the inspection one person was going to visit their boyfriend. This promotes people’s emotional wellbeing as it makes them feel secure. All of the people living in the home have a key to their bedroom if they wish and their rights to privacy are respected. We saw evidence that a number of people did use their key to lock their bedroom doors. The home has a keypad system for the front door when leaving the home and a key operated lock for entering it. If people do not have access to a key or the keypad code this is recorded on their risk assessment, which ensures their rights are respected. Staff were seen to interact with the people living in the home in a warm sensitive manner. The home has a number of menus, which were made available to the inspector. There is a vegetarian menu available for those people living in the Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 16 home that are Hindu. A non-vegetarian menu. There is also the individual menu that is competed by the person who shops and cooks for themselves to assist them with their independence. This person also works as a volunteer for and identified agency and undertakes paid work within the organisation. This further empowers her/him to continue to progress towards increased independence. The kitchen was clean and tidy. The fridge and freezer were inspected, which were hygienic. Food identified was labelled and stored correctly. Clear records were being kept with regard to fridge and fridge freezer temperatures. There were colour coded chopping boards to prevent cross contamination during the preparation of food. This protects the health and well being of the people living in the home and the staff who work there. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People receive support in a way they prefer. This means their personal wishes are respected. People’s physical and emotional health care needs are met, which safeguards their health and wellbeing. The process for administering medication is effective and promotes the good health of people living in the home. EVIDENCE: The record of people’s health care appointments for each person was inspected. They indicated that people are receiving regular input from healthcare professionals including CPN’S General practioners, Psychiatrists, opticians and dentists, which ensures their health is being monitored. The health information was effectively recorded and organised. The documents provided clear information with regard to the outcome of appointments. A consistent process with regard to the recording of information is being used which improves the quality of care provided to the people living in the home. There was a record of people’s weight charts, which are being kept up-to-date. This means that people’s weight monitoring programme is being effectively monitored which assists to promote people’s health and well being. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 18 The people living in the home need varying degrees of support with their personal care. The care plans inform staff with regard to how to support the people living in the home in the way they prefer or require. This ensures their views are listened to. The records indicate that one person living in the home may be assisted by a member of the management team in one of the other homes within the organisation that is of the same ethnic background with regard to their specific personal care needs. This ensures that the person’s individual needs are met and promotes their self-esteem. The registered manager informed the inspector that he is competent to perform basic nail care when necessary. This promotes the health and wellbeing of the people living in the home. The previous inspector had seen a certificate of competence from a podiatrist at the previous inspection to confirm adequate training had been provided to undertake this task. Medication was appropriately stored and the medication administration records for the people living in the home were inspected. The records were found to be in order. This promotes the good health of the people living in the home. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, People who use the service experience an excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. People who are living in the home can be confident that their views are listened to an acted upon since the recording and action taken in relation to complaints was found to be in order. People are protected by clear adult protection policies and procedures, which protects the people living in the home from abuse neglect and self-harm. EVIDENCE: The home had a clear up to date complaints procedure that had been reviewed in 2008 by the proprietor. This ensures that clear up to date procedures are available to the people living and working in the home. This promotes their rights and ensures complaints are taken seriously. The complaints book was inspected and there had been four complaints made since the previous inspection. The individual people living in the home had recorded the complaints. The information had been recorded the document had been signed and dated and responded to appropriately. The people living in the home are provided with a copy of the complaints procedure as part of the service users handbook, which they are given when they first move into the home. This ensures that their rights are protected as they have been informed about the complaints procedure and how to make a complaint if they wish to make one. The home had a copy of the current adult protection guidance issued by the London Borough of Enfield, the local authority the home is situated in. The Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 20 registered manager also made available for inspection a copy of the organisations detailed adult protection policy and procedure. This document was being reviewed to show the latest local authority contact details for mental health services. The whistle blowing policy was seen which the organisation are in the process of reviewing. Once again a list is available to indicate that staff have read the document and understood it. This is an example of good practice as the management team are putting procedures in place to ensure that staff are kept up to date with all policies and procedures. This improves the quality of care people receive. A list of the staff that had undertaken adult protection training was made available to the inspector. This ensures that staff have been provided with the necessary knowledge and skills to protect people from potential abuse. No allegations or disclosures of abuse had been reported since the last key inspection. When the inspector spoke in private with people living in the home they express no concerns about the home. They were clear in relation to their right to express concerns and knew who to express their concerns or complaints to. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30, People who use this service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. People are living in a clean, comfortable and safe environment, which benefits their health and wellbeing. EVIDENCE: Roland Care home Compton Road is a two-storey terrace house with a loft extension. On the ground floor there are two bedrooms, which overlook the garden. There is also a toilet, a kitchen and a lounge/dining room. On the first floor, there are three bedrooms and a toilet/accessible shower. There are two bedrooms, an office and a bathroom on the second floor (loft extension). There is a small parking space at the front of the home and a garden at the back of the home. The garden is paved and fully accessible for the people living in the home. This provides them with a pleasant place to relax in when they wish during the warmer months. People living in the home have their own bedrooms. People’s bedrooms were inspected having sought their permission. On the day of the inspection the bedrooms were found to be appropriately furnished. The rooms were Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 22 personalised with people’s own individual items, such as televisions, music centres and Ipods, which make the people living in the home feel secure in their chosen environment. The home is comfortable safe and free from offensive odours. This provides people with a pleasant home to live in. The kitchen was clean and tidy. This protects the health and well being of the people living in the home and the staff who work there. The kitchen was appropriately equipped to enable staff to meet people’s needs when they when they are being assisted to prepare meals or cook meals independently. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33,34,35,36, People who use the service experience a good outcome in this area. This judgement has been made using available evidence including a visit to this service. An effective competent staff team is able to meet the needs of the people living in the home. There is a robust recruitment procedure in place, which, contributes towards people being protected from potential abuse. Staff are appropriately trained to meet the needs of the people living in the home. Staff are well supervised, which benefits the people living in the home as a consistent approach by staff can be maintained to assist to meet people’s individual needs. EVIDENCE: The home has an established stable staff team. The names of nine staff were recorded on the homes staffing list. The home has no vacancies at the time of the inspection. Staff can work at any of the provider organisation’s registered homes although they are primarily based at one of them. This means that short- term vacancies can be covered without the organisation having to use agency staff. This ensures that consistent good quality care is provided to the people living in the home. A satisfactory staff rota was seen. There were adequate numbers of staff on shift to meet the needs of people living in the home on the day of the inspection. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 24 A number of staff had completed their National Vocational qualification (NVQ) level 2, and 3 and information is clearly documented on people’s files to evidence this. The registered manager is also a qualified NVQ assessor. This assists to ensure that professional practice is followed. Having had a discussion with the management team and looked at the training documentation on file it was evident that staff have also undertaken training in first aid, medication, fire safety, infection control, adult protection, toe nail cutting, manual handling, dementia care, hepatitis C and HIV training. This ensures that staff have the necessary training and skills to meet the needs of the people living in the home. Staff recruitment policies and procedures and relevant documentation was inspected and showed evidence of good quality robust recruitment procedures. The files contained criminal records bureau checks (CRB) and protection of vulnerable adults (POVA) clear application forms, two references, birth certificates and a copy of the person’s passport. They were found to be in order. This protects the people living in the home from potential abuse. The supervision records of staff indicated that staff are receiving regular supervision. This means that staff are being supported to work with people living in the home in a consistent way. This improves the quality of care for the people living in the home. Staff also receive an annual appraisal. This assists them with regard to their own professional development. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, People who use the service experience an excellent outcome in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and staff working there benefit from a very well run home. An effective Quality assurance system that takes into account the views of the people living in the home is in place. This assists with the continued self-monitoring and development of the home. People’s health safety and welfare is fully promoted and protected. EVIDENCE: An experienced registered manager manages the home. The manager has passed his Registered Manager’s Award. This means the manager has the skills and knowledge to run the home effectively and it is a well run home. The manager was very knowledgeable with regard to the people living in the home and their specific needs, which assist to ensure people’s individual needs, are met. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 26 The Registered manager showed the inspector an established Quality assurance system including feedback from people living in the home and other stakeholder surveys. The most recent Quality assurance survey was undertaken in 2008. The inspector saw evidence of a professional person who was thanking the home for the excellent care provided. The inspector is sent regulation 37 notifications of incident forms. This means that the manager ensures that legal requirements are met and professional practice is followed. A range of health and safety documentation was seen that included a gas certificate, electrical installation certificate, portable appliance testing certificate, fire evacuation procedures and servicing and testing of the home’s fire fighting equipment. The home has an up-to-date fire risk assessment. The home has a current public liability insurance certificate. All of the records were found to be in order and indicate that the home takes health and safety seriously. This promotes the health and safety of the people living in the home and the staff that work there to support them. Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 27 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 X 2 4 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 28 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 YA9 Regulation 15 (2) Timescale for action The Registered Person must 15/10/08 ensure that the identified person that obtains his/ her own finances from the bank but does not provide full receipts to the manager has the management of their finances risk assessed with the involvement of relevant professionals. This will ensure that agreed practices are in place that will assist with the development of the person’s own financial management including the management of their bankcard. The Registered Person must 20/10/08 ensure that the identified person who states they will make allegations against staff when professional boundaries are set for this person must have this issue risk assessed and linked to their individual care plan. All instances of this must be fully recorded and made available to relevant professionals. This will ensure that an effective means of recording this information is available to assist with any future developments. This can DS0000010635.V371322.R01.S.doc Version 5.2 Page 29 Requirement 2. YA9 15 (2) Roland Care Home (Compton Road) also be used to promote this persons own personal development. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Roland Care Home (Compton Road) DS0000010635.V371322.R01.S.doc Version 5.2 Page 31 - 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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