Inspection on 19/10/05 for 63 Eton Avenue

This inspection was carried out on 19th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63 Eton Avenue 08/11/07

63 Eton Avenue 26/10/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 63 Eton Avenue 63 Eton Avenue North Wembley Middlesex HAO 3AZ Lead Inspector Sue Mitchell Announced Inspection 19th October 2005 10:00 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 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 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 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. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 63 Eton Avenue Address 63 Eton Avenue North Wembley Middlesex HAO 3AZ 020 8782 8629 020 8902 0933 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) First Choice Care Services Mr Kudzai Mafuba Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: First Choice Care Services is a private company providing care and accommodation for adults with learning disabilities within Brent. 63 Eton Avenue is situated in a quiet residential area of Sudbury close to shops, local transport and a range of leisure facilities in both Harrow and Wembley. The house is a three bedroom two story detached property. There is an ensuite bedroom, large kitchen, lounge /dining room, toilet and spacious conservatory on the ground floor. There are two single bedrooms, bathroom, a staff sleeping in room and office on the first floor. A well kept garden is to the rear of the property. There is restricted parking to the front of the house with space for one car on the drive. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, as this was the first one since the home was registered in August 2005. All three residents were present during the inspection and spent some time talking with the inspector about their life in the home and their activities. There had been a serious fire in their previous home, also owned by First Choice Care Services, and they had had to live in a hotel until the new home was registered. The manager and staff were helpful and informative throughout the inspection process. The proprietor was present during the inspection. There was a social work student on placement who also participated in the inspection. The inspection covered the majority of key standards. The residents showed the inspector around their home. What the service does well: What has improved since the last inspection? What they could do better: It was positive to note that this first inspection only identified six minor shortfalls in meeting standards. A recommendation was also made for the manager to contact the pharmacist to provide training on the monitored dosage system. The manager must ensure that that a procedure is in place for staff to follow when they fill a resident’s the insulin pen with the insulin capsule. The manager must review the sleeping in pattern as these were noted to be separate from shifts. There must be a record of breaks taken for staff working long days on the rota. The home has only been in operation for a matter of weeks but the manager needs to devise a system of monitoring activities/ records/ systems as part of the quality assurance system. The proprietor must now commence monthly Regulation 26 visits to the home and send a copy of the report to CSCI. The home’s health and safety systems were 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 6 in place but the manager must update the homes reporting policy and procedure to refer to the reporting of significant events to CSCI 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. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 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 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5 The resident’s needs are regularly reviewed. They signed new contracts when they moved into the home. EVIDENCE: The residents who live in the home were living together in the previous home. Their needs have not changed since the last inspection of that home in March 2005. Care plans have been updated on a regular basis. New contracts were issued to each resident when they moved into Eton Avenue and were on the resident’s files and had been signed by them. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 The residents are fully involved in their care planning. They participate in regular house meetings where their views are listened to. The residents are supported to lead independent lifestyles and risks are clearly identified with them. EVIDENCE: One care file was sampled. The care plan had been recently reviewed and identified the individual’s goals and tasks. The residents confirmed that they attended their reviews. There were working care files in place which contained all the current working documents staff needed i.e. care plan, risk assessments, behaviour monitoring, day activities and appointments. It was evident through discussion with the residents that they are able to make day to day decisions about their lives, choices of activities and friendships. There are residents meetings as well which are recorded. Staff were able to tell the inspector how they supported the residents in their daily living activities ensuring that they led an independent lifestyle but also being mindful of any risks. Clear risk assessments had been written for each person identifying high, medium and low risks with guidelines to minimise the risks. The home also uses ABC charts to record incidents. The residents manage their own finances on a day to day basis. Records of expenditure were assessed and found to be in order. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 The residents enjoy an active social life within the community and are supported to access local facilities. Families and friends are made welcome within the house. The residents are offered and enjoy healthy meals of their choice. EVIDENCE: The residents spent some time with the inspector discussing their activities, friendships and college courses. Two are at college on an employment skills course, which includes numeracy and literacy. One person expressed the wish to learn to read and write properly and said that college was helping him. Another person is on a cookery course and said that he was going to organise for his class to go out for a Chinese meal at Christmas. The proprietor stated that she had arranged for a tutor from BACS to come that day to discuss providing private tuition with the residents on a range of subjects of their choice. The residents are able to choose their own community activities such as swimming and using the local library. They had recently been to London to the British Museum and found that interesting. The proprietor said that it had taken a bit of time for the residents to get used to living in a new area. The residents said they liked the new area as it was close to shops and transport into both Harrow and Wembley. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 11 The residents discussed their plans for Christmas and hoped to have a party. They said they had been to Butlins in Minehead for their summer holiday. They showed the inspector photos of their holidays and other trips out and parties they had been to. The residents discussed their families and friends, their visits home and that their friends and families had been to see them in their new home. One person stated that he was going home for the religious Muslim festival Ede and was looking forward to that very much. The inspector sampled lunch with the residents. It was freshly cooked with rice, meat and vegetables and a fruit dessert. It was very appetising and the residents clearly enjoyed the meal. They said they are involved in cooking, preparing meals and setting tables and washing up. One person suffers form epilepsy and so is cautious about being in the kitchen without staff being present. One person is diabetic and so staff are mindful of the types of food he should avoid. A menu was made available for inspection and found to be varied with an emphasis on fresh foods. The residents are able to discuss and plan their own menus. They said they have a take away on Fridays of their choice 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20 The residents are supported to access local health care and medical services. Medication administration is safe. EVIDENCE: The residents have been registered with the local health care services. There was a record of all appointments with outcomes in their files. One person is epileptic and there was a record of their seizures in place. Another person is diabetic and self-administers his insulin using an insulin pen. Staff fill the pen with the insulin capsule, when it has run out, and ensure the resident is administering the correct dose. The resident is unable to do this himself. There must a procedure in place for staff to follow to this effect. The home has monitored dosage system (MDS) in place using dossett boxes. The manager stated that he is to discuss another form of MDS with the pharmacist as the lids from the boxes slide off quite easily. There is a detailed medication policy in place. The manager was advised to contact the pharmacist for training on the use of the MDS when it is changed. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The residents are able to voice any concerns with staff and know to whom to complain. There are policies in place to protect the residents from harm. EVIDENCE: There have been no complaints made to or about the home. There is a robust complaints procedure in place, which is also in the service users guide. The residents said they knew to whom they could complain and that they had no complaints or issues to raise with the inspector. The home has a robust adult protection policy and procedure. Staff have had adult protection training and were able to discuss the issues relating to adult protection with the inspector. There are policies relating to service users finances, whistle blowing and managing challenging behaviour. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 The residents live in a homely, comfortable and well furnished home. EVIDENCE: The residents showed the inspector around their home including their rooms. They expressed pleasure in having all new equipment as much had been damaged or lost in the fire. The home was well decorated and furnished in a homely manner. The home was fully compliant with the registration requirements for the new premises and had had all the appropriate checks from the Fire Brigade and Environmental Health Officer. The registration officer had made a condition of registration that as one bedroom was undersized the proprietor was to apply to have an extension to increase the bedroom size. The proprietor stated that this was in hand and would be completed within the timescale. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 The residents are supported by a stable and well trained staff group. All staff undergo thorough recruitment checks before working with the residents. EVIDENCE: The rota was made available for inspection, two staff are rota’d on duty for each shift. Staff work long and short days. There must be a record of breaks taken for staff on the rota. The manager must review the sleeping in pattern as these were noted to be separate from shifts as some staff just come in to sleep in. If staff agree this practice then a record must be made of this decision. The manager also works some shifts to support staff and the residents in their activities. The residents do not attend day centres and are supported by staff to access community facilities such as college, libraries, sports centres etc. The residents participate in the cleaning of the home with staff as well as assisting in preparing meals as part of their care plans. There had been no changes to the staff group who had previously worked in the resident’s previous home. Staff records had been checked in that home at the inspection in March 2005 and found to be in order. The student social worker informed the inspector that she had had a CRB check carried out by the college before starting her placement. She was supernumerary and worked on shift with the staff and residents. The new manager stated that he was in the process of carrying out training needs assessments with staff but had only been in post for two weeks prior to the inspection. He said he would be drawing up a training plan for 2006-07 when this was completed. There was a training programme for staff for 200563 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 16 06 in place and there was a clear record of all staff training undertaken over the past year. Core training and refresher training had been carried out. The home had purchased training packs on Health and safety, food hygiene, moving and handling, adult protection, fire safety and medication. The manager is a qualified trainer and will be carrying out in house training with staff. Two staff are in the process of doing NVQ3 training and one is to do the NVQ4. Staff spoken to stated that they had good support from the manager and proprietor. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The residents are protected from harm by the home’s health and safety policies and regular checks of appliances. The manager has had appropriate experience to run the home in a competent manner. Quality assurance systems will need to be developed, which will include resident’s views. EVIDENCE: The manager had recently been registered by CSCI and all checks had been carried out prior to his appointment and registration. The manager is experienced in working with people with learning disabilities and mental health needs. There is a quality assurance policy in place. The home is very new and will need time to develop its quality assurance system. This will be reviewed at the next inspection. A system of monitoring activities/ records/ systems within the home must be developed. The proprietor must commence monthly Regulation 26 visits to the home and send a copy of the report to CSCI. The registration process included checking that all certificates relating to the appliances used in the home were correct. Fire safety checks and drills are carried out regularly and recorded. Staff have had all relevant health and safety training. The manager must update the homes reporting policy and 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 18 procedure to refer to the reporting of significant events to CSCI (ref Regulation 37) 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 63 Eton Avenue Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000064941.V250440.R01.S.doc Version 5.0 Page 20 NA 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 2 Standard YA20 YA32 Regulation 13(2) 18(1)(a) Requirement There must a procedure in place for staff when they fill the insulin pen with the insulin capsule. The manager must review the sleeping in pattern as these were noted to be separate from shifts. If staff agree this practice then a record must be made of this decision. There must be a record of breaks taken for staff working long days on the rota. A system of monitoring activities/ records/ systems within the home must be developed. The proprietor must commence monthly Regulation 26 visits to the home and send a copy of the report to CSCI. The manager must update the homes reporting policy and procedure to refer to the reporting of significant events to CSCI Timescale for action 30/11/05 31/12/05 3 4 YA32 YA39 18(1)(a) 17 30/11/05 31/12/05 5 YA39 26 30/11/05 6 YA42 37 31/12/05 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 21 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 YA20 Good Practice Recommendations The manager was advised to contact the pharmacist for training on the use of the MDS when it is changed. 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. Extracts may not be used or reproduced without the express permission of CSCI 63 Eton Avenue DS0000064941.V250440.R01.S.doc Version 5.0 Page 23 - 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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