Inspection on 17/06/08 for Boniville House

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Boniville House 28/06/07

Boniville House 09/05/06

Boniville House 08/11/05

Boniville House 14/04/05

Boniville House 28/01/05

Boniville House 30/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Boniville House 17 Melrose Avenue London NW2 4LH Lead Inspector Tony Lawrence Key Unannounced Inspection 17th June 2008 09:15 Boniville House DS0000017469.V364422.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 Boniville House DS0000017469.V364422.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. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boniville House Address 17 Melrose Avenue London NW2 4LH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8450 1755 0208 830 6984 boniville_house@yahoo.co.uk Mrs Mabel Dingiswayo Mrs Mabel Dingiswayo Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only- Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 5 28th June 2007 Date of last inspection Brief Description of the Service: Boniville House is a registered care home that provides accommodation and support for a maximum of 5 residents with mental health problems. When we visited, two men and two women were living in the home and there was one vacancy. 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 daytime, 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. Information regarding the level of fees may be obtained, on request, from the manager of the home. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. This unannounced key inspection took place on Tuesday 17th June 2008 from 09:15 – 16:30. We spent time talking to residents and staff on duty and the home’s owner / Manager. We also saw all communal parts of the home and some residents’ bedrooms. We ‘tracked’ the care of two people living in the home. We did this by talking with both residents and staff who support them and checking care records kept in the home. All 4 people who live in the home, 1 relative / carer, and 3 other people sent us confidential surveys. Their comments are included in this report. We would like to thank the residents, manager and staff for their time and help with our inspection. What the service does well: What has improved since the last inspection? What they could do better: 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 Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 6 be made available in other formats on request. Boniville House DS0000017469.V364422.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 Boniville House DS0000017469.V364422.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): 1, 2 and 5. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People know the home will meet their needs and preferences as it has developed clear information to help them understand what specialist services the home can provide. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a service user’s guide. EVIDENCE: ‘I chose to live here. I had all the information I needed’. (Comment from a resident). ‘I visited the home before I decided to live here’. (Comment from a resident). ‘I knew I was coming here and I knew it was all right. I liked it’. (Comment from a resident). ‘The Service User Guide is available to all prospective residents and their families. It provides clear information about the terms and conditions of the contract, fees and any extra charges. Staff go through the service user guide with every prospective resident and their families to ensure they fully Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 9 understand the terms and conditions of a placement’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we saw that the home’s Statement of Purpose and Service User Guide were both reviewed and updated in 2007. Both documents included all of the information needed to meet these Standards. The Statement of Purpose was detailed and included the provider’s expectation that residents’ human rights and diversity are respected. The Service User Guide and admission procedure included pre-admission visits and overnight stays. It was not possible for us to assess how this works in practice, as there had been no admissions to the home since 2002. We did review the admission records of two residents and these included a care needs assessment and occupational therapy assessment that were completed before each person moved into the home. The home’s owner / manager told us that there was a block contract with Brent Social Services and residents also had an individual contract that explains their rights and responsibilities. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents know their care needs will be met as the service involves them in the planning of care which affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives. People living in the home are encouraged to make their own decisions and choices. EVIDENCE: ‘I make decisions about things most days’. (Comment from a resident). ‘My key worker talked to me about my care plan and I signed it’. (Comment from a resident). ‘I ask the staff’s permission if I wish to go out somewhere so that staff know my whereabouts’. (Comment from a resident). Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 11 ‘All care plans are drawn up in conjunction with the service user and their families. The care plan is written in plain English and is easy to understand. Care plans and risk assessments are reviewed every six months’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we checked the care plans of two people living in the home. We saw that both care plans had been written in March 2008 and there was good evidence that both residents had been involved in developing their plans. Both plans were signed by the resident and their key worker. The plans covered people’s mental and physical health needs, as well as social activities, the management of medication, social activities, contact with family and friends, personal care, cultural and spiritual needs. Both plans gave us a good overview of what each person could do for themselves, their daily routines and areas where they needed support. There is a need to make sure that, where needs are identified, the ways these will be met are agreed with the resident and included in the plan. For example, one person’s plan said that they should be supported to visit the temple more regularly, but there was no information about how staff would support the person to achieve this. We saw evidence that each person’s care plan was reviewed every six months. Before the review meeting, key workers completed a detailed pre-review assessment with the resident to monitor any changes in their care needs. Both of the care plans we reviewed during this visit included a number of risk assessments that had been reviewed and updated in April 2008. The risk assessments covered smoking, vulnerability, self-neglect, challenging behaviours and management of medication. We felt the assessments were well written and included good guidance for staff on ways that identified risks could be minimised. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. Residents can access and enjoy the opportunities available in their local community, such as using public transport, library services, the local pub, and local leisure facilities. More could be done to involve people in the domestic routines of their home. EVIDENCE: ‘The home supports individuals to live the life they choose to their optimum level with support from all involved in their care’. (Comment from a health care professional). ‘Residents are encouraged to develop local community contacts. One resident was supported to access the Mind befriending service; another was supported Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 13 in their search for a Muslim support group’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). Both of the care plans we checked during this visit included a questionnaire that residents had completed, giving information about their likes, dislikes, hobbies and interests. During this visit we also checked the daily care records kept by staff for all four people living in the home. People living in the home told us that they did go out most days and mentioned cafes, pubs and a local hairdresser. Lack of detail in the daily records made it difficult for us to see if residents were taking part regularly in appropriate activities. To show that residents are getting the care and support detailed in their care plans, there is a need to make sure that staff record more detail about residents’ activities during the day, in the evenings and at weekends. Most daily care notes were very brief, with staff recording only that people ‘went out’ or ‘went shopping’. One person’s records did include more detail about their daily activities and staff must make sure that this standard is reached for each person living in the home. We saw that details of residents’ families, friends and other significant people were well recorded in their care plans. Residents told us that, if they needed support, staff helped them to keep in touch with these people. Daily care notes showed that residents are involved in domestic tasks around the home. People told us that this mostly involved cleaning their rooms and communal areas. Residents said that staff cooked all meals and there was little opportunity for them to cook, although two people told us that they would like to do this occasionally. During this visit, the member of staff on duty spent the morning in the kitchen, cooking the residents’ lunch; we saw no residents involved and felt that staff should offer people more opportunities to take part in cooking their own meals. ‘A weekly menu planning meeting takes place between residents and staff. Residents choose what meals they would like to be included in the weekly menu. The menu is varied and reflects individual and dietary needs’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). While we also saw that the home’s Statement of Purpose said that three choices were offered at lunchtime, there is a need to make sure that this happens in daily practice. When we visited, the menu showed chicken curry and rice for lunch, with chocolate éclairs for dessert. One resident’s care plan said that they were vegetarian but no choice was available. The resident told us that, while vegetarian food was sometimes available, he ate chicken and fish when there was no option. The provider and staff working in the home must make sure that vegetarian choices are available at each meal time, if this is requested by residents. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 14 The home’s dining room is bright, spacious and well furnished. Residents told us that they chose to eat meals together. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 15 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): 18, 19 and 20. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents know that their personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan or health action plan. Plans give a comprehensive overview of their health needs and act as an indicator of change in health requirements. The home has an efficient medication policy supported by procedures and practice guidance, which staff understand and follow. Medication records are fully completed, contain required entries, and are signed by appropriate staff. EVIDENCE: ‘I tell staff if I need help and they help me’. (Comment from a resident). ‘I can go to the doctor when I want to’. (Comment from a resident). ‘The home attends to residents’ mental health and social needs. They ensure services are provided as required and when necessary. They deal well with residents’ medication and liaise well with other professionals’. (Comment from a health care professional). Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 16 ‘Residents are assisted in receiving regular support from the community health teams and other health care professionals. Staff also assist and encourage residents to attend all medical and health care appointments’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). The two care plans we reviewed during this visit included good information about each resident’s daily personal care needs, including any support they needed with bathing, washing, shaving and other personal care tasks. During this visit we saw that the health care needs of the two residents we reviewed were well assessed and recorded. Both care plan files included good records of residents’ appointments with their GP and other healthcare professionals, including local mental health services. Health care records also included monthly weight and blood pressure records for each person. This showed that staff were able to monitor changes in residents’ physical health. The records showed that one person’s medication had been reviewed in May 2008. Residents told us that staff would help them to make health appointments, if necessary. We saw that the home uses the Boots monitored dosage system for the management of each resident’s prescribed medication. We saw that all prescribed medication was securely stored in a lockable cabinet. When we visited, the provider told us that no controlled medication was used in the home. We checked the Medication Administration Record (MAR) sheets for all four people living in the home. We saw that the records were well completed by staff and we found no errors or omissions. Staff told us that they checked the medication for each person at the daily handover between morning and afternoon staff and we saw that both staff signed the record. There is a need to clarify with one person’s GP whether their medication should be given twice a day or ‘as required’. In this one case, the medication records were unclear and the provider and staff need to make sure that clear guidance is provided. Four health care professionals who returned confidential surveys commented positively on the way residents’ health care needs are met in the home. One person added ‘we would continue to refer clients as they benefit from living in this home’. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 17 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): 22 and 23. People living in the home experience Adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are aware of the complaints procedure, but may not realise the importance of listening to, and then acting on residents’ concerns. Complaints from individuals are not always fully recorded. When they are logged, the records may be incomplete, with timescales, outcomes and actions not being properly logged. Links with external agencies are adequate but there is a lack of understanding of safeguarding procedures and how they work. EVIDENCE: ‘If I’m not happy I’d speak to the manager or staff (any member of). I know how to make a complaint’. (Comment from a resident). ‘I was given a copy of the complaints procedure’. (Comment from a resident). ‘When I got upset over something I have discussed it with the staff and manager and they seemed to have listened and sorted it out’. (Comment from a resident). ‘The complaints procedure is explained to each resident and they are given information about how to refer their complaints to external bodies, such as the CSCI, if they wish to do so’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). During this visit we saw that the home had a clear complaints procedure that included the Commission’s contact details. We saw that there had been 9 Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 18 formal complaints since our last inspection in June 2007. There was a need to make sure that complaints were fully and clearly recorded, to show that the home responded appropriately to residents’ complaints. In one case, an allegation of theft was recorded, but the staff response was poor. There was no recording of the outcome of the person’s complaint and there was no referral to the police or the local authority. All four people living in the home returned confidential surveys we sent them. All four people told us that they knew who to speak to if they were not happy and that they knew how to make a complaint. While we saw that the home had some information about safeguarding adults and a ‘whistle blowing’ policy, the provider must obtain a copy of the local authority’s safeguarding adults policy and procedures and make sure that staff working in the home follow these. The guidance provided for staff was outdated and needed to be reviewed to make sure that staff followed the correct procedures for responding to allegations or suspicions of abuse. The two staff on duty during our visit told us that they had completed safeguarding adults training in May 2008, but one person was unsure of the procedures to be followed and neither person was aware of the need to follow the local authority procedures. The provider must also make sure that events recorded as complaints, and any other incidents affecting residents’ welfare, are reported to the Commission. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 19 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): 24, 25, 27, 28 and 30. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is a pleasant, safe place to live and the bedrooms and communal rooms meet these Standards. Residents are encouraged to personalise their bedrooms. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. EVIDENCE: ‘I like my room, I’ve got everything I need’. (Comment from a resident). ‘The home provides a safe and therapeutic environment which is comfortable and accommodates the service users’ needs’. (Comment from a health care professional). ‘Residents can bring their own furniture and can choose colour and decorations scheme. They can also personalise their bedrooms in any way they choose, subject to health and safety requirements’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 20 The home is located in a residential part of Willesden and is close to local shops and transport links. There is off street parking for 2 cars. The home is indistinguishable from neighbouring properties and is suitable for use as a care home. The home is not accessible to people with mobility problems, as there are internal stairs to the bedrooms. The property consists of ground, first and second floors. 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 an attractive garden at the rear of the premises. During this visit we saw all communal parts of the home and some residents’ bedrooms, with their permission. The communal lounge and dining room on the ground floor was well decorated and comfortably furnished. There was a TV with DVD player and a selection of films, books and board games in the lounge. The kitchen was well equipped. The staff office was also small but well equipped. The bedrooms we saw were comfortably furnished, well decorated and very individual. Residents told us that they liked their bedrooms and chose to spend time there in the evenings and other times when they wanted privacy. There were two bathrooms with WC and wash hand basin. During this visit, all parts of the home we saw were clean, tidy and hygienic. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 21 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): 32, 34 and 35. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by staff who receive relevant training that is focussed on delivering improved outcomes. The home puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people in a person centred way. EVIDENCE: ‘I get on well with the staff’. (Comment from a resident). ‘I’ve learnt a lot here and the training and support have been very good’. (Comment from a member of staff). ‘We have developed a thorough recruitment procedure. This ensures that we employ good quality carers who can meet the needs of our residents and provide an excellent service delivery. Our recruitment procedure is highly competitive and ensures the right person is selected for the job, rather than a vacancy simply being filled’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 22 During this visit we spoke to staff working in the home and checked the personnel staff files for two people. Staff told us that they enjoyed working in the home and commented that there was always access to relevant training, including National Vocational Qualification (NVQ) training. The Manager told us that it had been difficult to find permanent staff with the necessary experience and qualifications and agency staff covered two care assistant posts. Staff on duty when we visited knew the care needs of each resident and how these should be met. They worked well together to make sure that residents received the care and support they needed. The two personnel files we checked were well organised and included all of the information needed to make sure that people are safely cared for, including copies of application forms, written references and Criminal Records Bureau checks. Both files also included a copy of the person’s passport as proof of identity. To make sure that staff are working legally, the provider must make sure that staff who are working with a student visa do not work more than 20 hours per week in the home. The records showed that both members of staff had completed a detailed induction training course and an annual appraisal had been completed with both people in November 2007. We felt that the practice of staff wearing a uniform top was institutional and should be reviewed by the provider. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 23 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): 37, 39, 40, 41 and 42. People living in the home experience Good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. The Annual Quality Assurance Assessment (AQAA) contained clear, relevant information that was supported by a wide range of evidence. The AQAA let us know about changes they have made and where they still need to make improvements. The data section of the AQAA was accurately and fully completed. EVIDENCE: ‘I find the manager a helpful lady, always nice to talk to’. (Comment from a relative). ‘Quality monitoring takes place on a monthly basis covering a different service area each month. An action plan is developed to address any areas for Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 24 improvement that are identified by the quality monitoring’. (Comment from the provider’s Annual Quality Assurance Assessment – AQAA). The manager told us that she is a qualified nurse and midwife with more than 20 years experience of working with people with a mental illness. She has also completed a counselling qualification and is currently completing her National Vocational Qualification (NVQ) Level 4 award for registered managers. We have registered the manager as a fit person to own and manage a care home. We felt that the provider had implemented good systems for reviewing the quality of care provided in the home. Quality assurance questionnaires are sent to residents’ relatives and health and social care professionals each year. People living in the home are also given a survey form each month that asks for their views on an aspect of the services provided. Topics have included activities, religion / belief, meals, visitors, environment and health care. The residents’ responses are collated and analysed each month by a member of staff and the information gathered is used to inform the home’s annual quality assurance report. The manager returned our Annual Quality Assurance Assessment (AQAA) before this visit. The AQAA contained clear, relevant information and included evidence that all of the policies and procedures required to meet these Standards have been developed for use in the home. Staff told us that the policies and procedures were available for reference and we saw that each policy had been reviewed in 2006 or 2007. During this visit we reviewed a number of care records kept in the home, including residents’ care plans and risk assessments, medication records and daily care notes. We felt that standards of record keeping in the home were good. During this visit we saw no health and safety issues. The home had records of regular health and safety checks and service records for equipment used in the home. The provider confirmed that health and safety risk assessments had been completed, including a fire safety risk assessment. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 3 3 3 X Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 26 No 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 15 (1) Requirement To show that residents’ care needs are met, specific goals and objectives must be included in care plans. Care plans must also show how residents will be supported to achieve identified objectives. To show that residents are getting the care and support detailed in their care plans, there is a need to make sure that staff record more detail about residents’ activities during the day, in the evenings and at weekends. To make sure residents’ dietary needs are met, the provider and staff working in the home must make sure that vegetarian choices are available at each meal time, if this is requested by residents. To make sure that residents’ health care needs are met, the provider must clarify with one person’s GP whether their medication should be given twice a day or ‘as required’. To show that the home responds appropriately to residents’ DS0000017469.V364422.R01.S.doc Timescale for action 30/09/08 2. YA12 15 (1) 30/09/08 3. YA17 16 (2) (i) 30/09/08 4. YA20 13 (2) 30/09/08 5. YA22 22 (3) 30/09/08 Boniville House Version 5.2 Page 27 6. YA23 13 (6) 7. YA23 37 (1) 8. YA33 19 (1) complaints, staff must make sure that complaints are clearly recorded, together with action taken and outcomes. To show that residents are cared for safely, the provider must obtain a copy of the local authority’s safeguarding adults policy and procedures. Staff working in the home must make sure that they follow these procedures. To show that staff take appropriate action when caring for residents, the provider must make sure that the Commission is told about any events or incidents affecting residents’ welfare. To make sure that staff are working legally, the provider must make sure that staff who are working with a student visa do not work more than 20 hours per week in the home. 30/09/08 30/09/08 30/09/08 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. 2. Refer to Standard YA17 YA33 Good Practice Recommendations Staff should offer residents more opportunities to take part in cooking their own meals. The provider should review the practice of staff wearing uniform tops when they work with residents. Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Boniville House DS0000017469.V364422.R01.S.doc Version 5.2 Page 29 - 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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