Inspection on 08/11/07 for 63 Eton Avenue

This inspection was carried out on 8th November 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63 Eton Avenue 26/10/06

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 HA0 3AZ Lead Inspector Andreas Schwarz Key Unannounced Inspection 8th November 2007 09:30 63 Eton Avenue DS0000064941.V345373.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 63 Eton Avenue DS0000064941.V345373.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. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 63 Eton Avenue Address 63 Eton Avenue North Wembley Middlesex HA0 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.V345373.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 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. The house is a three bedroom two storey detached property. There is one 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 currently one vacancy in the home. There is restricted parking to the front of the house with space for two cars on the drive. Fees and charges can be obtained from the registered manager or registered provider on request. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place during a day in November 2007. The deputy manager assisted me; the registered manager arrived after lunch. The home has forwarded a completed and detailed Annual Quality Assurance Assessment within the given timescale. I spoke to both people currently using the service at lengths and people using the service provided me with excellent information about the support they receive in the home. I viewed care plans and other relating documents and records during this unannounced key inspection. I would like to take this opportunity thanking everybody involved in this unannounced key inspection. What the service does well: What has improved since the last inspection? What they could do better: 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 6 I have made five new requirements during this key inspection. Meals are of good standard, but the home must provide cultural appropriate meals more regularly. Records of what meals have been consumed by people using the service must be provided for inspections. The home must ensure people using the service safety and fit window restrictors. Staff must be supervised regularly to meet the required six planned supervisions per year. The home must forward a copy of the completed annual development plan to the Commission for Social Care Inspection. The home must undertake regular gas and electrical safety checks to ensure people using the service life in a safe environment. 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. 63 Eton Avenue DS0000064941.V345373.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 63 Eton Avenue DS0000064941.V345373.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. The assessment is conducted professionally and sensitively and involves the individual. EVIDENCE: Since the last key inspection one person moved out of the home, the home did not have any new admissions since than. Previously assessment standards have been assessed as good. People using the service informed me that they remember having an assessment, which was undertaken by the registered provider. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. The care plans are person centred and are agreed with the individual. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. EVIDENCE: I have viewed both care plan files during this key inspection; both have been reviewed in May 2007. People using the service informed me that the next review meeting is arranged for November 2007. People using the service told me that they know about their care plan and that they are involved in the care planning processes. Care plans are person centred and people’s development and goals are clearly recorded. The home is currently in the process of exploring occupational and recreational activities within the local and wider community. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 10 People using the service told me that they could choose what they want to do, this was observed during this visit. Staff asked both people where they would like to go to lunch. I checked both money tins during this inspection. I noted that, the actual money recorded did not tally with the amount in people’s tins; both tins were over. I informed the deputy manager that this must be resolved and people’s financial records must be correct. People using the service informed me that staff helps them with finances and benefits. One person using the service acts as his own appointee, peoples contributions are clearly recorded. The home has a wide range of risk assessments in place, risk assessments have been reviewed during care plan reviews and people using the service are involved in this process. Risk assessments are available electronically and as paper copies. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a strong commitment to enabling people who use services to develop their skills. People who use the service have the opportunity to develop and maintain important personal and family relationships. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. They can access and enjoy the opportunities available in their local community, e.g. using public transport, library services, the local pub, and local leisure facilities. Opportunities are available for residents to be involved in food shopping. There is however little reflection of the cultural dietary needs of individuals. EVIDENCE: People using the service access local days services, which is documented in their care plans. People using the service informed me, that they go to computer classes run by Brent Learning Disabilities Partnership. Staff 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 12 supports people using the service to get to their day centres and activities. One person informed me that he would like to find paid employment, this was discussed at lengths with the registered manager and I informed the home that this should be addressed during the next care plan review. One of the people living in the home is taking language classes. People using the service told me that they go swimming, go to the gym and meet friends. These activities have been recorded clearly and a timetable is available. People using the service informed me that they go to the library to get videos and music tapes in their own language, and that they are able to vote. The rota reflects adequate staffing during weekdays and weekends. One person using the service informed me of having a girlfriend, which he sees regularly. Families are actively involved in one of the people’s lives. People using the service can build new friendships during activities at the apple club, during meals out or during their annual holidays, etc. People using the service went to Butlins for their holiday, this year. People using the service told me that they have their own bedroom key. Mail is given to them unopened. People using the service have chosen clothes and both people were dressed very smart. I observed people using the service relaxing in their rooms if they want to. People using the service informed me that they help staff with household activities such as clearing the table, making tea, wash clothes; staff is supporting them if they experience difficulties. The home has a smoking policy in place. Meals are nutritious, healthy and of good standard. People using the service informed me that they could choose what they want to eat. Records of meals have been of poor standard and the home is required to provide clear records of what people using the service have eaten. One person using the service informed me that he likes curries and other cultural foods, which are not available that often. The home must review this and ensure to provide culturally appropriate food regularly. The kitchen was clean and tidy and temperature recordings are in place. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use services receive effective personal and healthcare support using a person centred approach. Staff members are very alert to changes in mood, behaviour and general wellbeing and fully understand how they should respond and take action. Health Action Plans have also been developed in line with current good practice guidance. Staff is trained and competent in health care matters. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. EVIDENCE: People using the service told me that they are able to wash themselves; one person said that he needs help with washing his back, which is done by staff. The home has records in care plans of what support people using the service require. All people using the service are fully mobile and no equipment is required. People using the service told me that they go to a local barber for haircuts. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 14 People using the service showed me in the diary when they last went to see the dentist, chiropodist, optician, etc. The home has clear guidelines for specific conditions and illnesses in place. All people using the service are registered with a General Practitioner of their own choice, who undertakes regular health checks. The registered manager has provided a Diabetes pack and Diabetes management plan for people using the service. The pack is available in a user-friendly format and is used for staff training. Medication Administration Sheets had no gaps and a detailed medication policy is in place. Medication is stored in a lockable cabinet or a fridge, which is located in the locked office. The registered manager who is also a qualified nurse is providing medication training by using a training pack purchased from an accredited training provider. People using the service medication are reviewed regularly. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has an open culture that allows people using the service to express their views, and concerns in a safe and understanding environment. The service has a complaints procedure that is clearly written and easy to understand. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Training of staff in the area of protection is regularly arranged by the Home. EVIDENCE: The homes complaints policy has been reviewed in December 2006 and is compliant with National Minimum Standards. People using the service informed me that they would complain to the manager. The home had no complaints since the last inspection and people using the service told me that they do not have any complaints about the home. A copy of the complaints policy is available in bedrooms. The home has an adult protection policy in place, which has been reviewed in December 2006. The registered manager informed me that he is providing Protection of Vulnerable Adults training, using a training manual from an accredited training provider. Staff demonstrated understanding of who to report allegations of abuse to. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. People who use services are encouraged to personalise their bedrooms. All the homes fixtures and fittings meet the needs of the individuals and can be changed if their needs change. The home is well lit, clean and tidy and smells fresh. EVIDENCE: I toured the building. People using the service expressed satisfaction with the facilities that the home provides. The home was well decorated and furnished in a homely manner. The registered manager informed me that the extension of one of the rooms has been completed. The registered manager informed me that there are no window restrictors on the first floor, which is required. The home has a garden, which is in need of maintenance. This was discussed with registered manager. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 17 The Control of Substances Hazardous to Health cupboard was found to be locked and the home was clean and free of any offensive odours. The home informed myself in their Annual Quality Assurance Assessment that policies relating to the Health and Safety have been reviewed. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 18 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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff members undertake external qualifications. People who use the service report that staff working with them are very skilled in their role, and are consistently able to meet their needs. There are enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The service has a good recruitment procedure that clearly defines the process to be followed. EVIDENCE: I have viewed two staff files all files contained the necessary checks such as references, right to work in the United Kingdom, Criminal Records Bureau checks, visa status, etc. The home is using a company to obtain Criminal Records Bureau checks; the registered manager informed me that the home is now obtaining Criminal Records Bureau checks on an annual basis. The home employs seven staff, who provide 24-hour support. All staff is from African background, people using the service are British or from Asian 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 19 background. It is recommended to employ staff; which reflects the cultural background of people using the service. The home has a number of training videos from accredited training providers in place. The registered manager is a qualified learning disabilities nurse and is providing specialist training to staff. Staff has a training and development plan in place. I could not find clear evidence of staff receiving a minimum of six supervisions per year; this is required. New staff receive an in house induction before they are allowed to work unsupervised. In addition to this all staff undertake the Skills for Care Induction. Four out of seven staff have or work towards their National Vocational Qualification in Care, this meets the National Minimum Standards. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 20 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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager has the required qualification and experience, is competent to run the home and meets its stated aims and objectives. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is aware of the need to promote safeguarding and has developed a health and safety policy that generally meets health and safety requirements and legislation. 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 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 21 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 manager is a qualified Learning Disability nurse. People using the service spoke positively about the manager, and told me that they like him. The home has a quality assurance policy in place, which has been reviewed in January 2006. The registered manager informed me that the home send out surveys to people using the service and stakeholders. The annual development plan has not been completed, this is required and a copy must be send to the Commission for Social Care Inspection. People using the service informed me that they have regular meetings to discuss issues of concern. I have viewed the homes fire policy, fire risk assessment, the fire alarm is tested weekly and fire drills are undertaken monthly. All fire records were up to date and in order. The manager informed me that the Portable Appliances Test Certificate and Landlords Gas Safety Certificate has expired; the home must send copies of both documents to the Commission for Social Care Inspection. 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 X 3 X X 2 X 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 23 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 YA17 Regulation 16(2)(i) Requirement The home must ensure to provide more culturally appropriate meals. The home must provide clear records of food and meals provided to people using the service. The registered manager must ensure that all windows on the first floor are fitted with restrictors. The registered manager must ensure that all staff receive six planed and recorded supervisions per year. 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. A copy of this report must be send to the Commission for Social Care Inspection. (Previous Timescale of 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 24 Timescale for action 15/12/07 2. YA17 17(2) Schedule 13 13(4)(a) 01/12/07 3. YA24 01/01/08 4. YA36 18(2) 01/01/08 5. YA39 24 01/01/08 30/01/07 not met) 6. YA42 13(4)(c) The registered manager must ensure to forward a valid copy of the Portable Appliances Test Certificate and Landlords Gas Safety Certificate to the Commission for Social Care Inspection. 01/01/08 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 YA12 Good Practice Recommendations The home should discuss paid employment opportunities for people using the service during the up coming care plan review. The home should try to employ staff from a cultural background similar to people using the service. 2. YA32 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 63 Eton Avenue DS0000064941.V345373.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!