Inspection on 15/12/05 for 3, Park Avenue

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

3, Park Avenue 03/10/07

3, Park Avenue 08/08/06

3, Park Avenue 06/06/05

3, Park Avenue 13/10/04

3, Park Avenue 21/06/04

3, Park Avenue 10/02/04

3, Park Avenue 13/11/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Park Avenue, 3 Mitcham Surrey CR4 2EQ Lead Inspector Liz O`Reilly Unannounced Inspection 15th December 2005 10:00 X10015.doc Version 1.40 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 Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 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 Older People. 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. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Park Avenue, 3 Address Mitcham Surrey CR4 2EQ 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 8286 1206 Mr Nizma Hosanee Mr Feeroz Hosanee Mrs Nazma Bibi Hosanee Care Home 3 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3), Old age, of places not falling within any other category (3) Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: 3 Park Avenue is a care home for up to three adults over the age of sixty five all of whom have mental health needs. The home is owned by Mr N. Hosanee and Mr F. Hosanee. The home is situated in a residential area of Mitcham, is in keeping with the local neighbourhood and is not identifiable as a care home. Residents have easy access to public transport and a group of local shops. The aims and objectives of the home are set out in the Statement of Purpose which is available in the home and in the Service User Guide a copy of which is supplied to each resident. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one regulation inspector on 15th December 2005 over two and a half hours. The inspector had the opportunity to speak with each resident, the registered manager and one of the owners of the home. A sample of records were examined. What the service does well: What has improved since the last inspection? What they could do better: Staff in the home need to consult with residents on a regular basis in relation to the food provided in the home to ensure the cultural needs and wishes of residents continue to be met. The Registered Person need to complete the annual review of the home taking into account the opinions and wishes of residents. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 6 The Registered Person needs to supply to the CSCI a copy of the audited accounts along with the costed development plan for the home taking into account the maintenance of the home. 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. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 The needs and wishes of residents are assessed before they move into the home. This assists in ensuring that the home can meet the needs of each individual. EVIDENCE: The home receives a copy of the care management assessment carried out by social services before any person moves into the home. Staff from the home will also carry out an assessment of individual needs and wishes. These assessments are used to compile an initial care plan for each person which ensures that staff are aware of the needs and aspirations of each resident. At the time of the last inspection a requirement was made for staff to be provided with ongoing training on caring for people with mental health needs. This training has been commenced. A requirement was also made for a review of the care and food to be carried out to make sure the cultural needs and wishes of residents were met. The manager confirmed that this review had taken place and changes had been made according to residents wishes. Residents confirmed they were happy with the care and choice of food. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 9 Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 The needs and wishes of residents are set out in individual care plans. The health care needs of residents are met. The management of medication assists in ensuring the health and welfare of residents. EVIDENCE: Care plans set out individual needs, objectives, actions to be taken and by whom. Care plans are reviewed on a regular basis. Care plans cover the physical, social, emotional and cultural needs and wishes of each person. Good information was seen to be available to staff to assist them in supporting each resident. Care plans are compiled and reviewed in consultation with the resident. Individual risk assessments are also in place. Staff keep good daily records which set out the daily activities of each person. These records are written by the staff on duty at the time as required at the last inspection. All residents are registered with local GP services and arrangements are in place for residents to receive regular health care checks. Should any resident Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 11 require nursing input this is provided by the community nursing services. The home has good links with community psychiatric services who can be called upon for advice if required. The recording and storage of medication is well managed. Staff administering medication have completed accredited training on the management of medication in care homes. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Residents confirmed they were happy with their day to day activities. All residents were satisfied with the food provided. The opinions of residents in relation to food need to be sought on a regular basis. EVIDENCE: Activities in the home are flexible to take into account the wishes of residents on a day to day basis. Residents said they could join in activities if they wishes or opt out. One resident said they enjoyed visits from their family and going out with them. Another resident said they liked going out shopping and that staff would go out with them if they wished. Residents confirmed they could attend religious services of their choice outside the home either supported by their relatives or staff. Residents were complimentary about the meals provided. They felt they had “plenty” to eat and that staff were “good cooks”. Alternatives are available at each meal times. Snacks and drinks are available at all times. One residents commented that the meals on offer were “not always” what they would normally eat. The inspector is aware that the manager has reviewed the menu since the last inspection of the home to take into account the cultural needs and wishes of residents. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 13 It is recommended that the menu for the home is discussed at each residents meeting and that residents are asked for suggestions for meals. Staff monitor the weight of each resident and take action should there be any concerns regarding nutrition. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 A complaints procedure is in place and made available to residents. Satisfactory procedures are in place for the protection of residents from abuse. EVIDENCE: The home provides residents with information on making a complaint. Residents said they had no complaints about the service. The home keeps a record of any complaint along with details of any investigation and outcomes. No complaints have been received by the home or the CSCI since the last inspection. Since the last inspection of the home staff have been provided with guidance on dealing with aggressive behaviour. Staff have also received in house training, from the Registered Person, on the protection of vulnerable adults. The manager should ensure that details of the contents of any in house training are kept on file in the home. The manager and owners are aware of their role and responsibilities regarding reporting any allegation or suspicion of abuse to the appropriate persons. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The environment is maintained to a satisfactory standard. The home is clean, tidy and free from offensive odours. EVIDENCE: Park Avenue is a domestic style home which is maintained to a satisfactory standard. Since the last inspection the lounge has been redecorated. The garden area has been cleared ready to be planted out for the spring. As noted in previous inspection reports the kitchen for the home is showing signs of wear and tear. The Registered Person agreed that the kitchen would be refurbished by November 2006. Domestic style laundry facilities are available in the home which is in keeping with the small scale style of the home. Policies and procedures on the control of infection are in place for staff. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 16 The Registered Person should ensure that the development plan for the home contains an annual programme for the maintenance of the home including redecoration and refurbishment. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 30 The home has sufficient staff on duty to meet the needs of the present resident group. Training ensures residents are supported by a well informed staff group. EVIDENCE: A minimum of one member of staff is available in the home at all times. At the time of this visit the registered manager and one carer were on duty. At night one member of staff sleeps in the home. These staffing levels are sufficient to meet the present needs of the group. The manager monitors the staffing levels and keeps a record of any instances where the person asleep in the home is called upon at night. The manager confirmed that residents have not needed any assistance at night. The manager and one of the home owners live next door and can be called on at night if needed. Staff are provided with training opportunities and have received training in food hygiene, equal opportunities and the protection of vulnerable adults. Two of the three staff have received accredited training on the management of medication. All staff are provided with copies of the homes’ policies and procedures. Since the last inspection individual training records have been compiled for each staff member. Evidence of a minimum of three paid days training each year is in place. As noted previously a record of the contents of in house training should be retained in the home. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 & 38 Further work needs to be done to complete the report following the annual review of the service. The registered persons need to provide evidence to show the business is financially sound. Staff carry out regular checks on the premises and equipment to ensure the health and safety of residents. EVIDENCE: In order to show that the home is run in a manner which takes into account the wishes and views of residents the registered persons need to complete the annual review of the service, produce a report and publish residents feedback. A copy of the report produced needs to be sent to the CSCI. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 19 The Registered Person must supply to the CSCI a copy of the audited accounts for the home along with the annual, costed, plans for the maintenance, upkeep and development of the home. Satisfactory records of money held on behalf of residents are in place. Residents can deposit small amounts of cash in the home for safekeeping. The manager has improved the way in which records are kept for this money and two staff, as well as the resident, now check and sign each transaction. Records of regular checks on the fire detection system, fridge and freezer temperatures and electrical equipment were up to date. Data is kept in the home on any cleaning materials and monthly health and safety checks are carried out on the home. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 2 3 x x 3 Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 21 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 OP15 Regulation 16 (2) (i) Requirement Timescale for action 01/04/06 2. 3. OP19 OP33 16(2)(g)2 3(2)(b) 24 The registered persons must continue to consult with residents on a regular basis on the food provided to ensure that the cultural needs and wishes of residents are fully met. The registered persons must 01/11/06 ensure that the kitchen is refurbished. The registered persons must 01/05/06 ensure that a copy of any report produced following annual review of the service is supplied to the Commission. Timescale of 15/09/05 not met. The registered persons must supply to the Commission a copy of the audited accounts for the home along with a business and financial plan. Timescale of 05.01.05 and 15.09.5 not met. 01/05/06 4. OP34 25(2) (3) Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 22 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 OP30 Good Practice Recommendations The Registered Persons should ensure that information on the contents of in house training sessions is retained in the home. Park Avenue, 3 DS0000027263.V277667.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: 0845 015 0120 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. 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