Inspection on 14/04/05 for Boniville House

This inspection was carried out on 14th April 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Boniville House 17/06/08

Boniville House 28/06/07

Boniville House 09/05/06

Boniville House 08/11/05

Boniville House 28/01/05

Boniville House 30/04/04

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

CARE HOME ADULTS 18-65 Boniville House 17 Melrose Avenue Willesden London NW2 4LH Lead Inspector Julie Schofield Unannounced 14 April 2005 9.40am 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 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 Stationary 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. Boniville House Version 1.10 Page 3 SERVICE INFORMATION Name of service Boniville House Address 17 Melrose Avenue Willesden London NW2 4LH 020 8450 1755 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Mabel Dingiswayo Mrs Mabel Dingiswayo CRH, PC 5 Category(ies) of MH (5) registration, with number of places Boniville House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th January 2005 Brief Description of the Service: Boniville House is a care home and accommodates a maximum of 5 residents with mental health problems. The home is located in a residential part of Willesden and is close to local shops and transport links. Parking is restricted in the street outside the property during the day time, Monday to Saturday. There is off street parking for 2 cars. The property consists of a ground, first and second floor. There are 5 single bedrooms, one of which has en-suite facilities. There are two bathrooms, each containing a toilet. The office is situated on the ground floor. There is a small garden at the rear of the premises. Boniville House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Thursday in April 2005. It started at 9.40am and finished at 3.50pm, lasting for a total of 6 hours 10 minutes. During the inspection the Inspector had discussions with the manager, a member of staff and 4 of the 5 residents and would like to thank them for giving their comments. Staff and care records were inspected. A partial site visit took place including 2 of the service users’ bedrooms. What the service does well: What has improved since the last inspection? The manager is in the process of reviewing and updating key policies and procedures and in producing a staff handbook. Boniville House Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Boniville House Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Boniville House Version 1.10 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 standard(s) 2,4 A comprehensive assessment of need by the placing authority enables the home to determine whether the service provided would be appropriate for the prospective resident. Residents are involved in the process of choosing a care home that can meet their needs and make their decision after an introductory visit(s) to the home. EVIDENCE: On the case files there were copies of care plans from the placing authority, comprehensive assessment of need forms from the placing authority and risk assessments that were carried out prior to the resident’s admission to the home. The manager said that this information was necessary before she could decide whether to accept the referral and to go ahead with the pre-admission process. A resident recalled the time prior to their admission to the home and said that they had visited the home, with their social worker. They had been given a choice of bedrooms and they still occupied the room, which they had chosen. They had spent some time in the home and the manager said that they had also visited the home on their own. They had looked at the local area and had formed a good impression of the home and the service being offered. They told their social worker that they would like to move in and this was arranged quickly. Another resident also confirmed that they had visited the home before their admission. Boniville House Version 1.10 Page 9 Boniville House Version 1.10 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Residents’ needs are assessed and reviewed on a regular basis. Providing residents with a copy of their care plan would enable them to be actively involved in monitoring their progress towards meeting the goals that have been identified. Residents are able to lead an independent life style, supported by risk assessment management strategies. EVIDENCE: Case files were inspected and care plans and minutes of review meetings were on file. The care plans were comprehensive and addressed personal, health and social care needs. They were accompanied by risk assessments. Review meetings referred to the care plan. One resident said that their review meeting was to be held during the next week. Residents were not provided with a copy of their care plan. The home has a system of key working and residents are aware of the name of their key worker and the names of professionals outside the home that support them. Minutes of CPA meetings and OPD meetings were on file. Case files contained risk assessments, which were tailored to the individual needs of residents. They included a risk assessment for smoking, going out, Boniville House Version 1.10 Page 11 violent outbursts, falling etc. Each risk assessment included a risk management strategy. The home has a missing person’s policy. Boniville House Version 1.10 Page 12 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 standard(s) 12,13,14,15,16,17 Residents maintain their independence by making use of services and facilities in the local community. A programme of leisure activities in the home would give residents an enjoyable, entertaining and stimulating structure to this part of their life. Residents are encouraged to keep in contact with their relatives in order to maintain family links and friendships. The daily routines and house rules encourage independence and respect residents’ privacy but the contract should include information about smoking, use of alcohol etc. Residents are able to exercise choice by being involved in the menu planning. The meal served during the inspection was not appropriate for one resident and an alternative should have been served so that they enjoy a nutritious and balanced diet. EVIDENCE: There was information on file that the home made referrals to the Quality Employment Support Team (QEST) but residents then changed their minds and decided not to accept this support. During the inspection 2 residents returned from a visit to the local shops and residents confirmed that residents walked, used local public transport or took Boniville House Version 1.10 Page 13 cabs to visit shops, post office cafes and restaurants. They were aware of their right to choose whether to be politically active and vote. The manager confirmed that when necessary, a member of staff was available to escort a resident. A programme of indoor daily activities was on display in the dining room and covered the period 11/4 to the 17/4/05. It included visits to the GP, shopping, laundry, staying in the home and there were a number of mornings and afternoons where there was nothing entered. The manager said that sometimes residents and staff would play card games and that there were a selection of board games for residents to use. Some of the residents confirmed that they have relatives who keep in touch with them and visit them at the home. They confirmed that their relatives were made welcome when they visited and visits can take place in the privacy of their own room. Examples were given by the manager of how the residents are encouraged to maintain contact with their relatives. Residents followed their own independent life style, entering and leaving the home as they wished. They were able to stay in their room without unnecessary interruptions and the manager or carer knocked on the bedroom door if they wished to speak to the resident. Residents confirmed that keys to the front door and bedroom door had been given to residents who wished to have these. There is a rota for staff helping in the kitchen and each resident helps with their laundry and keeping their room clean. Residents said that smoking was only allowed outside the house and they respected this. However, although the home has policies for smoking and drinking alcohol in the home the rules are not included in the contract. Residents confirmed that the time for breakfast was flexible and that some people ate after 10.00am. They said that they were able to choose their own meals and 2 residents said that they drew up the weekly menu with the member of staff on duty and that it was varied. The menu included choices, which met the religious and cultural needs of a resident. Lunch was a cooked meal and in the evening residents were either given money to purchase ingredients or were able to choose something from the kitchen to be prepared. Residents said that the staff preparing meals were good cooks. During the inspection lunch was served. The main course consisted of pork chops, roast potatoes and spinach and the dessert served was spotted dick with custard. One resident is Muslim and does not like vegetables. She had potatoes for lunch. The choice of food that the resident selected was recorded in their daily report book. Boniville House Version 1.10 Page 14 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 standard(s) 18,19 The personal care and health care needs of service users are met and their dignity and privacy is maintained. EVIDENCE: The manager said that residents required encouragement and prompting in respect of personal care, rather than direct assistance. Residents were satisfied with the level of support given. Within the staff team there were both male and female carers and the home operates a system of key working. There was a record on file of residents’ health care appointments, including optical checks, appointments with the psychiatrist, and visits by the CPN etc. There was a record of access to routine screening e.g. blood tests, blood pressure checks etc. During the inspection a resident went to see their GP. Another resident said that they had diabetes and they were pleased that a member of staff was available to escort them to their hospital appointments. Boniville House Version 1.10 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 standard(s) 22,23 Residents were confident to raise any concerns or complaints with the manager. All staff need training in the protection of vulnerable adults if the safety of residents is to be promoted within the home. EVIDENCE: There is a complaints procedure on display in the hallway, which refers to the previous regulatory authority. The procedure includes timescales for each stage of the process. Service users were aware of their right to complain about the service received and said that if they had any problems they could discuss them with the manager. The residents’ meeting was an opportunity to discuss the running of the home. The complaints book was produced and demonstrated that concerns were investigated and that residents were verbally informed of the outcome. The home has a copy of the local authority’s interagency guidelines in the event of abuse and there is a protection of vulnerable adults policy in place in the home, but it refers to the previous regulatory authority. The carer on duty confirmed that she had undertaken protection of vulnerable adults training although the manager said that not all members of staff had received this training. No allegations or incidents of abuse have been recorded since the last announced inspection and the manager said that restraint is not used in the home. There is a policy in respect of understanding physical and verbal aggression towards staff. The manager was unable to find the policy in respect of residents’ money and financial affairs and there is no policy in respect of a resident self-harming. Boniville House Version 1.10 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 standard(s) 30 The home is kept clean and tidy so that residents benefit from a hygienic environment. EVIDENCE: A partial site inspection took place, including the bedrooms of 2 residents that allowed access to their rooms. All areas seen were clean and tidy and the residents agreed that the home was always kept clean and tidy. However one room seen would benefit from airing during the day. The carer on duty confirmed that they had undertaken infection control training and the home has an infection control policy. The laundry is situated on the first floor and the facilities are suitable for residents to use. Boniville House Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,36 Staff working with residents who have mental health problems need training that will enable them to provide the residents with appropriate support. There were sufficient numbers of staff to support the residents and to provide an escort, when this was necessary. The recruitment process protects the safety of the residents. The absence of individual supervision sessions reduces the overall support available to staff and an opportunity to encourage personal development is missed. EVIDENCE: The carer on duty confirmed that they are undertaking NVQ level 2 training but they have yet to undertake mental health training. The rota was available for inspection. The home is maintaining the staffing levels agreed with the previous regulatory authority. The staff team consists of both male and female staff. There were no separate domestic or catering staff. The manager’s hours were recorded on the rota. Staff files demonstrated that the recruitment process of the home included the receipt of 2 satisfactory references, receipt of a satisfactory enhanced CRB disclosure and proof of identity (passport details). The carer on duty confirmed that this process had been followed when she had been employed. Boniville House Version 1.10 Page 18 The carer said that they were supported and supervised on a day-to-day basis and that they sometimes received an individual supervision session. Staff meetings took place and annual appraisals had been carried out Boniville House Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Training in safe working practice topics enables staff to be aware of and to promote the health and safety needs of residents. In order to meet satisfactory standards of fire safety the home needs to implement the requirements of the fire officer. EVIDENCE: During the inspection a representative from the LFEPA carried out an inspection of the fire safety systems, equipment and procedures. The manager said that requirements had been identified. Valid certificates were available for the portable electrical appliances testing, servicing of the fire extinguishers/alarms/smoke detectors etc, a Landlords Gas Safety Record and the electrical installation check. The carer on duty confirmed that they had undertaken training in safe working practice topics although there were not recorded risk assessments for all safe working practice topics. Boniville House Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x 3 Standard No 11 12 13 14 15 Boniville House x 3 3 1 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 x 2 Version 1.10 Page 21 16 17 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x Boniville House Version 1.10 Page 22 N/A 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 YA6 YA14 Regulation 15.2 16.2 Requirement That residents are given a copy of their care plan. That after consulting with residents, a programme of activities is drawn up, which provides stimulating and enjoyable opportunities for residents. That rules on smoking, alcohol and drugs are stated in the contract. That an alternative meal is served if a resident is unable to eat the meal prepared. That the complaints procedure refers to the CSCI and not the previous regulatory authority. That the protection of vulnerable adults policy refers to the CSCI and not the previous regulatory authority. That all members of staff undertke protection of vulnerable adults training. That the home has a policy on residents self harming. That staff have training in working with people with mental health issues. That staff receive individual supervision sessions, at least Version 1.10 Timescale for action 01 August 2005 01 August 2005 3. 4. 5. 6. YA16 YA17 YA22 YA23 5.1 16.2 22.7 12.1 31 May 2005 01 May 2005 01 July 2005 01 July 2005 01 August 2005 31 May 2005 30 April 2005 01 August 2005 Page 23 7. 8. 9. 10. YA23 YA23 YA32 YA36 13.6 12.1 18.1 18.2 Boniville House 11. YA42 23.4 once every two months, and that these are recorded. That the requirements made by the Fire Office are implemented within the timescales specified and that the CSCI is informed in writing by the home when compliance is achieved. 01 September 2005 or before. 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. 2. 3. Refer to Standard YA23 YA30 YA42 Good Practice Recommendations That a policy on residents money and financial affairs is drafted and implemented. That residents are encouraged to air their rooms during the day. That there are recorded risk assessments for all safe working practice topics. Boniville House Version 1.10 Page 24 Commission for Social Care Inspection 4th 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 Boniville House Version 1.10 Page 25 - 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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