Care Home: Sach Road (31)

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What the care home does well It is the inspector`s view that this is a generally well run home, and that service users receive a good level of care and support. Through surveys, service users expressed satisfaction with the home. One commented that "I am very happy at this home, I like all the staff." While a relative of one of the service users wrote, "My sister is very happy at Sach Road." The home seeks to meet the needs of service users around equality and diversity needs, and has drawn up an action plan to this end around how it can meet needs around cultural identity and religion etc. The home is well maintained, and service users have been able to personalise their own bedrooms. Service users have the opportunity of participating in a wide variety of community based activities. What has improved since the last inspection? There have been improvements to the home since the previous inspection, and this is evidenced by the overall number of requirements set, which has fallen from eleven to four. Service users now have routine access to dental care, and the home has a comprehensive medication policy in place. Staff have now received training around adult protection and health and safety matters. Systems are in place to monitor service users finances to help reduce the risk of financial abuse occurring. What the care home could do better: A total of four requirements have been made, which must be addressed. The home must ensure that care plans are subject to regular review, and that quality assurance systems are implemented which include seeking the views of service users. The home must implement a confidentiality policy, and ensure that at least 50% of the care staff team have a relevant care qualification. CARE HOME ADULTS 18-65 Sach Road (31) 31 Sach Road Hackney London E5 9LJ Lead Inspector Rob Cole Unannounced Inspection 5th June 2008 09:00 Sach Road (31) DS0000010285.V364952.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 Sach Road (31) DS0000010285.V364952.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. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sach Road (31) Address 31 Sach Road Hackney London E5 9LJ 020 8442 4253 020 8350 6723 sachroad@hotmail.co.uk 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) Mr Nonoy G Capina Goolam Hossen Adam-Saib Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2007 Brief Description of the Service: 31 Sach Road is a residential care home for five people with learning disabilities. The home comprises a two storey Victorian end of terrace property in a residential area in Clapton, in the London Borough of Hackney. The home is within walking distance from Lower Clapton Road, which has a parade of shops. Mare Street and Dalston shopping areas are accessible by transport links. The home is privately run. The current range of fees charged is between £700 and £1412 per person per week. Sach Road (31) DS0000010285.V364952.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 took place on the 5/6/08 and was announced. The inspector had the opportunity of speaking with staff from the home, and the homes joint proprietors were present throughout the course of the inspection. One of the five service users was at home during the course of the inspection. This service user has no verbal communication, but the inspector was able to observe staff interactions with this service users. The inspection included an examination of records and other documents, along with a tour of the premises. Prior to the inspection the home completed an Annual Quality Assurance Assessment (AQAA) at the request of the CSCI. In addition to this, surveys were completed by service users and their relatives, and all of this contributed to the overall inspection process, and to the judgments made within this report. What the service does well: What has improved since the last inspection? What they could do better: Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 6 A total of four requirements have been made, which must be addressed. The home must ensure that care plans are subject to regular review, and that quality assurance systems are implemented which include seeking the views of service users. The home must implement a confidentiality policy, and ensure that at least 50 of the care staff team have a relevant care qualification. 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. Sach Road (31) DS0000010285.V364952.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 Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that prospective service users are provided with sufficient information about the home in order for them to make an informed choice as to move in or not. This information is provided through written documentation and the opportunity of visiting the home. EVIDENCE: The home has both a Statement of Purpose and a Service User Guide in place. The Statement is written in plain English, and states that the aim of the home is to “Engender a homely atmosphere where residents enjoy a sense of security.” The Statement is subject to regular review, and includes details of the philosophy of care, the aims and objectives and of the management and staff team within the home. The Service User Guide has been produced in a combination of written and pictorial formats, thus helping to make it more accessible to service users and helping to meet their needs around equalities and diversity issues. The Guide has been revised since the previous inspection, and now includes details of the fees payable, what they cover, and what is not included in the fees. The Guide also includes details of the homes physical environment and a copy of the Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 9 complaints procedure, and is in line with National Minimum Standards (NMS). The home has also produced a brochure, which includes a summary of the Service User Guide including details of the facilities provided by the home. All service users have been provided with a written contract/statement of terms and conditions. As with the Service User Guide, these have been revised and now include details of the fees payable, along with the terms and conditions of occupancy. Contracts have been signed by the service user and the homes proprietor. There have been no new admissions to the home since 1998. The home does have an admissions procedure in place, which states that service users are able to visit the home before making a decision as to move in or not. Surveys completed by service users prior to this inspection confirmed that this was indeed the case. Service users will initially move into the home on a three month trial basis, after which a placement review meeting will be held. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors judgement that service users have control over their daily lives, and that they are involved in the day to day running of the home. EVIDENCE: Individual care plans are in place for all service users, four of which were looked at by the inspector. Care plans are drawn up with the involvement of the service user, their keyworker and the homes manager. Service users also have an annual review with their placing authority, which feeds into the care planning process. Care plans cover needs around health, medication and personal care, and have improved since the last inspection and now also cover needs around social and leisure activities and equalities and diversity issues, for example around how the home can meet the cultural or religious needs of service users. Daily logs are also maintained. However, care plans have not Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 11 been reviewed as regularly as is appropriate. For example, two care plans checked were dated from September 2007, and clearly stated that they were due to be reviewed in April 2008. However, these reviews had not taken place by the time of this inspection in June 2008. In order to ensure that care plans are kept up to date, and that they fully reflect the changing needs of service users, they must be subject to regular review, at least once every six months. Risk assessments are in place for all service users, and these have been subject to regular review. Assessments cover risks around health, mobility, and clear guidelines are in place around managing any challenging behaviours that service users present. Risk assessments identify any potential risks, and include strategies to manage and reduce those risks. There was evidence that service users are supported to take reasonable risks. For example, it has been identified that one service user who has autism enjoys going on holidays, and gets a lot out of a break away. However, the process of change involved with a holiday causes them anxiety. A risk assessment has been developed to work with this service to prepare them for their holiday and to provide reassurance around it. There was evidence that service users have choice and control over their daily lives, and that they are involved in the day to day running of the home. One service user commented in the CSCI survey that “I make my own decisions, and staff usually give me some choices.” While another said “They always give me choices what I want to do especially weekends.” Service users are involved in daily routines, for example setting the table, maintaining the garden and shopping, and this is detailed within their care plans. Service users are able to get up and go to bed at a time of their choosing, although staff will encourage service users to get up in time to attend various activities and appointments. On the day of inspection the one service user at home at lunchtime was seen to be offered a choice over their meal. The home has recently purchased a new sofa for the sitting room, and this was chosen by service users. The home holds regular service user meetings, which provide service users with the opportunity to discuss matters of importance to them, and to be involved in making decisions around the running of the home. Minutes of these meetings evidenced discussions around holidays and activities, along with other relevant topics including health and safety within the home. Occasionally the service users hold a meeting dedicated to a single topic. Recent examples include a meeting around equality and diversity issues, where service users had the opportunity to discuss what their needs and expectations were around things such as music and food provided in the home. Another meeting was held around the recent local government elections and how service users would be able to vote in these elections. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 12 Confidential records within the home are stored securely, and staff and service users can access their records as appropriate. Staff are expected to sign a declaration of confidentiality as part of their contract of employment. However, as at the last inspection, the home does not have a confidentiality policy in place. It is required that the home has a confidentiality policy in place, which includes details of when a confidence should be broken in the health, safety and welfare interests of service users and others. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that service users are supported to live valued and fulfilling lives. Service users have access to a variety of community based activities and services, and the food was of a satisfactory standard. EVIDENCE: No service users are currently involved in any employment, although two service users are involved with educational opportunities. One service user studies horticulture, while another studies IT skills. Four of the five service users attend a variety of different day services, and all four were out at day services during the course of the inspection. One service user attends a day service for adults with learning disabilities, where they are involved in various activities such as gardening, art and life skills training for Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 14 example around shopping and road safety. They have their lunch at this centre, which provides the opportunity of socialising and developing friendships. Another service user is a member of the “Me and My Life Project” which is run by the Local Authority, and arranges various outings such as to the theatre. They are also involved in a day service, where they participate in various activities including creative dance and drama, and they have also been involved with the staff recruitment process at this day service. Another service user is active in an Outreach service, which provides musical therapy, travel training and yoga. The inspector was pleased to note that three service users are involved in Haringey Councils “Valuing People” consultation process, giving them the opportunity to talk about what they want and expect from their placing authority. Service users have routine access to the local community, which helps to meet their needs around equalities and diversity issues. For instance, two service users attend a catholic church, and three service users are members of “Stars in the Sky”, an organisation for adults with learning disabilities designed to help promote and develop relationships with other people. Service users have access to other community facilities, including shops, markets, parks, banks and post offices. Service users regularly access public transport, including buses and trains, and the home has its own unmarked vehicle which service users use to access the community. Service users have access to a variety of social and leisure activities, both inhouse and in the community. In-house service users have access to television, videos, music and painting, and the home arranges occasional parties. On the day of inspection one service user was visited in the home by a masseur, which is a regular activity for them. In addition to activities arranged through the various day services, the home also supports service users to have access to community based social and leisure activities. For example, service users visit pubs, cafes, the cinema and the sauna. Service users eat at local restaurants, including English, Chinese and Caribbean restaurants, thus helping to meet needs around equality and diversity issues. The home organises occasional day trips, for instance to see the Christmas lights in the Westend and to Southend. Service users are supported to go on holiday, since the last inspection service users have been to France and Devon, and a walking holiday to Wales is planned for later this year. There was evidence through the service user meetings that service users are involved in planning and choosing holidays. Visitors are welcome to the home at any reasonable time, and service users can receive visitors in private if they so wish. The homes proprietor informed the inspector that service users are able to maintain contact with friends and family by telephone, and that they are given their own mail to open. Surveys received by the CSCI by relatives contained positive feedback about the home, Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 15 indicating that they are happy with the care and support provided, and that they are kept informed of any significant events. Records are maintained of menus, these indicated that service users are offered a varied, balanced and nutritious diet. Service users are involved with food preparation, including buying the food. The inspector was pleased to note that since the previous inspection fresh fruit is now available in the home. It was noted that staff offered the one service user at home during the inspection a choice for lunch, and that support with eating was provided in a sensitive manner. The kitchen was clean and tidy, and food was stored appropriately. The home tests the fridge and freezer temperatures on a daily basis. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the view of the inspector that the home is able to meet the personal and health care needs of service users. Service users have access to health care professionals as appropriate, and systems are in place to help ensure that medications are administered in a safe manner. EVIDENCE: Care plans contain information around service users personal care needs. These indicated that service users are supported to manage their own personal care as much as possible. The home operates a keyworker system, whereby all service users have a designated keyworker to help provide support in their daily lives and the care planning process. All service users are registered with a GP, and have an annual review of their medication with their GP. Records are maintained of medical appointments, including details of any follow up action necessary. Records indicate that service users have access to health care professionals as appropriate, including Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 17 opticians, occupational therapists and since the last inspection service users now have routine access to dental care. Individual health action plans are in place for all service users, which clearly set out how the home is able to meet the health needs of service users. For example, one service user has arthritis, and an exercise programme has been drawn up with the involvement of a physiotherapist which forms part of their health action plan. Service users needs around equality and diversity issues are also met through the use of health care professionals, for instance one service user has worked with a speech and language therapist to develop their communication skills through the use of objects of reference, thus helping them to make choices around their daily lives. Since the previous inspection the home now has a comprehensive medication policy in place, covering the ordering, receipt, storage, handling, administration, recording and disposal of medications. Medications are stored securely in a locked cabinet inside the office. All staff undertake training before they administer medication. No service users are currently on any controlled drugs, and no service uses self administer their medication. Records are maintained of medications entering the home, and of those that are returned to the pharmacist. The home maintains Medication Administration Record charts, those examined by the inspector were accurate and up to date. The home has sought and recorded the wishes of service users (or their family where appropriate) on the arrangements to be made in the event of their death. The proprietor informed the inspector that service users would be able to remain in the home with a terminal illness, so long as the home was able to meet their medical needs. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that the home has taken reasonable steps to help ensure that service users are safeguarded from the risk of abuse. All staff have undertaken training in adult protection, and the home has appropriate procedures in place around adult protection and complaints. EVIDENCE: The home has a complaints log, although the proprietor informed the inspector that no complaints have been received since the previous inspection. The home also has a complaints procedure, which makes reference to the CSCI and include timescales for responding to any complaints. All service users have been given their own copy of the procedure, and a copy is on display within the home. Surveys completed for the CSCI by service users indicate that service users know how to make a complaint, with one writing “I have information on how to make a complaint.” The home is situated in the London Borough of Hackney, and has a copy of the Borough’s adult protection procedure. The home also has its own policy on adult protection, which has been reviewed since the previous inspection and is now in line with current legislation. All staff have undertaken training in adult protection issues, and staff spoken to demonstrated a good understanding of their roles and responsibilities with regard to adult protection. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 19 The home holds money on behalf of service users in a locked cabinet. Service users have their own bank accounts. Records and receipts are maintained for financial transactions involving service users monies, and those checked by the inspector appeared to be satisfactory. Since the previous inspection financial risk assessments have been put in place, and systems have been introduced to monitor any monies that are withdrawn from bank accounts, which has helped to reduce the risk of financial abuse taking place. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspector’s judgement that the home is suitable to meet its stated purpose with regard to its physical environment. The home was generally well maintained, and service users have access to adequate private and communal space. EVIDENCE: The home is situated in the Clapton area of the London Borough of Hackney, close to shops, transport networks and other local amenities. The home is in keeping with other homes in the area. The homes communal areas consist of a sitting room, kitchen/dining room, visitor’s room and a well maintained garden, with appropriate garden furniture. The home was generally well maintained, both internally externally. Furniture and fittings in the home were domestic in character, and generally well Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 21 maintained. The inspector was pleased to note that the home has purchased a new sofa and chairs for the sitting room since the previous inspection, and that service users were involved in choosing this furniture. The home has also purchased a new dining table since the previous inspection. The home has one bathroom/toilet, one shower room and one two toilets on their own. The inspector was satisfied that the home has sufficient toilet and bathing facilities to meet the needs of service users. Bathrooms all had working locks fitted, which included an emergency override device. On the day of inspection bathrooms were clean, tidy and free from offensive odours, and all had soap and hand drying facilities as appropriate. All service users have their own bedrooms, which they have been able to personalise to their individual tastes, for example with televisions and family photographs. Service users needs around equalities and diversity issues are met through their room decorations, for example through religious iconography and posters and pictures representative of cultural and ethnic backgrounds. Bedrooms all have a hand basin in them. Bedrooms meet National Minimum Standards on size requirements, and have adequate natural light and ventilation. Central heating is provided in all bedrooms, and radiators had appropriate protective coverings in place. Bedrooms had appropriate furniture, including table and chair, chest of draws and a wardrobe. Curtains, carpets and bedding were well maintained and domestic in character. Bedrooms were clean and tidy on the day of inspection. The home has a separate laundry room, which has an impermeable floor covering. Laundry facilities were appropriate in scale for the home. Hand washing facilities were situated around the home, and to help prevent the spread of infection protective clothing such as gloves and aprons were available to staff. COSHH products were stored securely. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the inspectors view that the home is staffed in sufficient numbers to meet the needs of service users, and that staff have a good understanding of their roles and responsibilities. EVIDENCE: The home provides 24-hour support, including an emergency on-call procedure. The home had a staffing rota on display, which accurately reflected the staffing situation on the day of inspection. During the course of the inspection, only one service user was at home, supported by one staff member. The rota indicated that two staff or more are usually on duty when more service users are at home. Through observation there was evidence that staff have built up good relations with service users, and that they have a good ability to communicate with service users who have complex communication needs. Staff were seen to interact with service users in a friendly and respectful manner, and positive Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 23 interactions were noted, for example the sensitive support that was provided during mealtimes. Staff undertake a structured induction programme, which covers health and safety and service user issues. The home has developed a training plan, which states that all staff are entitled to three days paid training a year. Recent training has included medication and adult protection. The inspector was pleased to note that since the previous inspection staff have now received appropriate health and safety training, for instance around food hygiene and fire safety. At the time of the inspection, only two of the seven care staff employed at the home have achieved an NVQ Level 2 in Care or equivalent qualification (although several more staff are currently working towards such a qualification). This is short of the 50 minimum set out in the National Minimum Standards, and to help ensure that staff have the necessary skills, the requirement is repeated that at least 50 of staff obtain a relevant care qualification. Regular staff meetings are held, and all staff can contribute items to the agenda. Recent staff meetings have include discussions around the care planning process, equality and diversity issues and health and safety within the home. Staff receive regular formal supervision, and written records are maintained of this supervision. Supervision records seen by the inspector evidenced discussions around training needs and service user issues. The AQAA supplied by the home indicates that the home has relevant employment related policies in place, including on recruitment and selection and equal opportunities. The inspector checked several staff employment files at random, and these were found to contain all required documentation, including proof of ID, references and CRB checks. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43. People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is the judgement of the inspector that this is a generally well run and managed home. EVIDENCE: Since the last inspection the home now has a permanent manager in place who has been registered with the CSCI. The proprietors are also involved in the running of the home, and the rota indicates that they routinely work shifts at the home, as indeed they did on the day of inspection. Although the manager was not present during the inspection, there was evidence that they have a commitment to equal opportunities within the home, and that service users are encouraged to be involved in the day to day running of the home. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 25 Record keeping within the home was generally of a good standard, and confidential records are stored securely. The AQAA supplied by the home indicates that the home has appropriate policies and procedures in place. Policies checked by the inspector, including on medication and adult protection, were found to be satisfactory, with the exception of the confidentiality policy as already mentioned in this report. There are some systems in place which contribute to the quality assurance process within the home, such as staff and service user meetings, and staff supervisions. Copies of previous inspection reports are available to view in the home. However, the home does not have a system in place for seeking feedback from service users on the running of the home, and this has been highlighted within the AQAA supplied by the home as an area for improvement over the next 12 months. It is required that the home implements a quality assurance system, which involves seeking the views of service users, to help inform future planning within the home. Fire extinguishers were situated around the home, and these were last serviced in October 2007. Fire exits were free from obstruction on the day of inspection. Fire alarms are checked weekly, and were last serviced on the 11/4/08. The London Fire Authority visited the home on the 28/4/08 and found things to be satisfactory. The home has in date safety certificates for PAT testing, electrical installation and gas safety. Hot water and fridge/freezer temperatures are regularly checked, and COSHH products are stored securely. The home has in date employer’s liability insurance cover in place. Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 2 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 3 3 3 2 3 3 3 3 Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 27 Yes. 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 YA32 Regulation 18 Requirement The registered person must ensure that at least 50 of the care staff employed at the home achieve an NVQ Level 2 in Care or equivalent qualification. (Timescale 31/12/07 not met) The registered person must ensure that the home has a clear policy in place on confidentiality, which includes details of when a confidence may be broken in the health, safety and welfare interests of service users and others, and that all staff have a good understanding of the issues involved around confidentiality. (Timescale 30/09/07 not met) The registered person must ensure that care plans are subject to regular review, at least once every six months. The registered person must ensure that the home has a quality assurance system in place which includes seeking the views of service users on the running of the home, to help inform future planning. Timescale for action 30/09/08 2. YA10 13 31/07/08 3. YA6 15 31/07/08 4. YA39 24 31/08/08 Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 29 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 Sach Road (31) DS0000010285.V364952.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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