Inspection on 26/10/06 for 63 Eton Avenue

This inspection was carried out on 26th October 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 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 19/10/05

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 Dia Balraj Key Unannounced Inspection 26th October 2006 & 1 November 2006 7:45 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 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.V289037.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 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.V289037.R01.S.doc Version 5.1 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.V289037.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 October 2005 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 storey 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.V289037.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on a Thursday morning at 7.45 am and lasted 7 and a half hours. Service users were on half term holiday from the college except for one service user who had gone to visit his family. The inspector carried out a second inspection on the 1st November 2006 to meet with the third service user. These two visits enabled the inspector to gain insight into the standard of care from the perspectives of service users and staff. The interaction between service users and staff was also observed including breakfast and lunchtimes. The deputy manager was present during both inspections and facilitated the inspection by providing the required documents.. The responsible individual and the manager also came to the home and were interviewed. The inspector would like to thank the service users, the staff and management for facilitating the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Although there is good communication between service users and staff it is required that the 6 monthly reviews of service users are formalised and documented. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 6 Management must ensure that the extension to increase the bedroom size be finalised. 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.V289037.R01.S.doc Version 5.1 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.V289037.R01.S.doc Version 5.1 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. A thorough assessment of prospective residents’ needs is carried out to determine whether their needs can be met. EVIDENCE: The inspector obtained evidence from documentation, from observation and from discussion with the Deputy manager and staff. The documentation of the last admission was examined and included a Care Management assessment plan. There was also evidence of care assessments by the Manager. The latter contained information on health, social and emotional support, medication, managing finances and education. Restrictions on choice for example, the smoking policy were documented. Service users are able to smoke outside. Interviews with service users confirmed that visits to the home were undertaken and that they were able to meet with other service users and staff. The care plans examined identified residents’ needs and the required action to achieve objectives. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users’ needs are identified and they are enabled to make choices. They are encouraged to develop independence. EVIDENCE: The inspector interviewed service users and staff and viewed documentation of care plans. One care file was sampled. The care plan identified the service user’s individual goals. 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. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 10 The residents manage their own finances on a day to day basis. Records of the personal allowance of one service user was assessed and found to be in order. Two of the residents’ reviews were outstanding. Service users’ reviews must be carried out on a 6 monthly basis. A service user stated that although satisfied with his care he would like to consider living at home. It is required that management carries out a review of the placement of the service user concerned to ascertain the most appropriate way of meeting his needs and choices. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 11 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, 16, 17 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are enabled to undertake activities in the home and in the local community. Their rights are respected and they are offered a healthy diet. 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. The deputy manager stated that the home was currently exploring opportunities for work for service users. Staff also helped service users with benefits and finance problems. The residents are able to choose their own community activities such as swimming going out for walks and using the local library. Service users stated that they went to the gymnasium, cinema and had discovered local attractions such as funfair. Recently they had visited Chessington Zoo, Madame Tussauds, Buckingham Palace. Service users go out to the Discotheque once every month and have the opportunity to socialise with other homes when they attend the Apple Club. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 12 The residents discussed their families and friends, their visits home and that their friends and families had been to see them. A member of staff accompanies a service user to purchase Indian music tapes and facilitates him watching Indian movies on Sky TV. Another service user is supported to enjoy the music he loves and to purchase films, to go to the cinema and to Brent library. Service users were observed going in and out of their rooms and had a key to their bedrooms. Service users are supported to clean their bedrooms and smoking policy is clearly specified in the contract. The inspector observed the serving of lunch, which consisted of fish and chips and vegetables and a fruit dessert. Service users stated that they enjoyed their meal especially chicken. They said they are involved in cooking, preparing meals and setting tables and washing up. The menu made available for inspection was varied with an emphasis on fresh foods. The menu also addressed dietary and cultural needs with members of staff being able to prepare a variety of foods. Service users stated that they were able to discuss and plan their own menus. They said they have a take away meal of their choice on Fridays. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 13 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): 18, 19, 20 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users receive appropriate personal support. The health care needs of service users are met. Service users are protected by the home’s medication policy. EVIDENCE: The evidence under this section was obtained from viewing care plans, interviews with support worker and Deputy manager. The residents have been registered with the local health care services. There was a record of all appointments with outcomes in their files. Specific problems such as epileptic fits and self administration of insulin with an insulin pen were documented. Service users are offered minimum annual health checks including attention to vision and hearing. The home has monitored dosage system (MDS) in place using dossett boxes. The inspector viewed the MAR sheets. The Deputy manager stated that the MAR sheets coming from the Pharmacist had instances when the times for administering medication were incorrect. The inspector noted that the times had been changed by the home. The deputy manager stated that the staff were administering the medication at the correct time. There is a detailed medication policy in place. Management was advised to ensure that information on the MAR sheets is correct to avoid any medication errors. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 14 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 15 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. The complaints’ procedure ensures that concerns/complaints from service users and interested parties are acted upon. The POVA policy contributes to service users being protected from abuse. 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.V289037.R01.S.doc Version 5.1 Page 16 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, 30 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users live in a homely environment. The home is clean and hygienic. EVIDENCE: The inspector toured the building. Service users expressed satisfaction with the facilities that the home provides. 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 washing machine had the specified programming ability to meet disinfection standards. 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 the planning department had been contacted. It is required that the extension to increase the bedroom size be finalised. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 17 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are supported by competent and qualified staff. EVIDENCE: The home has a recruitment policy, which is based on equal opportunities and checks ensure the protection of service users. The home’s recruitment policy states that applicants must pass a CRB and POVA and POCA checks before being employed. They must also have 2 satisfactory current references and show that they are eligible to work in the UK. The two staff files checked confirmed the above. Staff interviewed stated that they had been given a copy of the GSCC code of conduct and induction standards. On the day of inspection in the morning there was one staff member on duty. The deputy manager and the support worker arrived later. The staffing ratio was judged adequate to meet the needs of the two service users present. The staffing establishment consists of the manager, deputy manager and 5 support workers. Two support workers hold the NVQ level 2 and three support workers are currently undertaking the NVQ level 3. The manager places great emphasis on the training of staff and the training profile identified the training needs of staff and provided training. There was evidence that each member of staff had followed Induction training, fire safety, Health and Safety, moving and handling, infection control, food handling, medication, and POVA. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 18 The manager is fully involved in the training of staff. Staff stated that their training included knowledge of disabilities and specific conditions of service users and a knowledge of their cultural backgrounds. The home has policies and procedures for dealing with challenging behaviour It is required that these guidelines be simplified so that it states the steps to be taken by staff to deal with each individual service user. . 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users benefit from a well run home. Service users are confident their views underpin all self-monitoring, review and development by the home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The manager is experienced in working with people with learning disabilities and mental health problems. He has management experience as a ward manager for 6 years and was appointed manager of this home in October 2005. The manager stated that he possesses a degree in Business Administration and an MA in health and social policy. He has undergone periodic training in fire safety and POVA. The manager has followed courses in management and discipline issues in the workplace. The home uses a quality monitoring checklist to assess various aspects of care in the home. Management must ensure that there is a quality assurance and quality monitoring system, which seeks the views of service users, family, friends and advocates and of stakeholders in the community. 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 20 The Employers Public Liability Certificate was displayed and expires 11/04/07. The home’s annual health and safety checks were in order. Health and Safety checks including fire alarms, emergency lighting and fire extinguishers were carried out on 30.10.06, The manager carries out weekly fire alarm checks and the person in control Regulation 26 visits were up to date. Risk assessments had been carried out 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 21 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 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 23 X 3 X X X 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X ENVIRONMENT Standard No Score 24 3 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000064941.V289037.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 63 Eton Avenue Score 3 3 3 X 3 X 2 X X 3 X Version 5.1 Page 22 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 YA6 Regulation 14(2) Requirement It is required that management carries out a review of the placement of the service user concerned to ascertain the most appropriate way of meeting his needs and choices. It is required that reviews are carried out at 6 monthly intervals. It is required that the extension to increase the bedroom size be finalised. It is required that the challenging behaviour guidelines be simplified so that it states the steps to be taken by staff to deal with each individual service user. Management must ensure that there is a quality assurance and quality monitoring system, which seeks the views of service users, family, friends and advocates and of stakeholders in the community. Timescale for action 30/11/06 2. 3. YA6 YA25 14(2) 16 30/11/06 30/01/07 4. YA35 12 31/12/06 5. YA39 24 30/01/07 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 23 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 63 Eton Avenue DS0000064941.V289037.R01.S.doc Version 5.1 Page 24 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. 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