Inspection on 08/11/05 for Boniville House

This inspection was carried out on 8th November 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 10 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 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 08/07/2008.

CARE HOME ADULTS 18-65 Boniville House 17 Melrose Avenue London NW2 4LH Lead Inspector Julie Schofield Unannounced Inspection 1:55 8 November 2005 th Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 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 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.V261218.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th April 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 daytime, Monday to Saturday. There is off street parking for 2 or 3 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 DS0000017469.V261218.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Tuesday afternoon, starting at 1.55 pm and finishing at 3.25 pm, and on a Friday morning, starting at 11.25 am and finishing at 2.15 pm. During the inspection a site visit, examination of records and discussions with the manager, staff and residents took place. The Inspector would like to thank everyone at Boniville House for their assistance. What the service does well: What has improved since the last inspection? Since the inspection in April 2005 the home has given residents a copy of their care plan so that the resident is aware of the service that they are entitled to receive and is able to monitor their own progress towards meeting agreed goals which were identified in their review meetings. The resident’s contract has been amended to include details of the rules regarding smoking. Staff have receive training in the protection of vulnerable adults and the manager has set up a programme of individual supervision sessions for permanent members of staff. New wooden flooring has been laid in the lounge. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 6 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. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was inspected during the previous inspection in April 2005. EVIDENCE: Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 Providing residents with a copy of their care plan enables them to be actively involved in monitoring their progress towards meeting the goals that have been identified. Residents exercise their right to make decisions about their life in the home. EVIDENCE: A statutory requirement was identified during the inspection in April 2005 that residents are provided with a copy of their care plan. There is now evidence on file that this has been carried out and the case file contains a record of the day on which this happened and the signature of the resident to acknowledge receipt. Discussions took place with residents and they confirmed that they made the decisions about how they lived their lives in the home. Residents come and go as they please and when the inspection started on the Tuesday afternoon only 1 resident was at home. During the inspection 2 residents returned from visits to the shops and 1 resident returned from a visit to the hairdressers. One resident described herself as an “indoor girl” and said that it was their wish to do things inside the home rather than to go out. They described their routine Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 10 and said that they decided what they wanted to do and that staff respected their privacy when the resident wanted to pray. They said that they decided what they wanted to eat each day and that when they wanted to, they ordered take away food. Another resident said that they decided what they wanted to do each day, that residents decided what was included on the weekly menu and that residents decided when they wanted they wanted to spend time in their rooms. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 16, 17 A programme of leisure activities in the home would give residents an enjoyable, entertaining and stimulating structure to this part of their lives and a programme needs to be developed. The respect for the resident’s right of choice was demonstrated in the way in which residents lived their lives, which was as they wished. Residents are offered a balanced and varied diet. Standards 12, 13 and 15 were inspected in the previous inspection in April 2005. EVIDENCE: Copies of the residents’ individual programmes of daily activities were available in the home. Rather than a record of what was to happen they were completed at the end of the day to record what had happened. Programmes included residents going to the post office, shopping, staying in their rooms, tidying their rooms (on 3 days per week), watching TV, reading, talking and going to the hairdresser. There were gaps on the programs where nothing had been recorded. Residents said that liked to go out shopping and one resident said that sometimes they went shopping or to a café with one of the other residents. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 12 Residents demonstrated an independent lifestyle as they entered and left the home as they wished. It was noted that staff knocked on the residents’ bedroom doors before being invited to enter. Residents have a key to their bedroom door and have a front door key. A statutory requirement was identified during the previous inspection in April 2005 that the contract contains the rules on smoking. The contract now states that smoking is only allowed in the garden. When the inspection commenced Tuesday afternoon the midday meal had already been served. Residents said that the meal had consisted of chicken curry and rice and this was the meal listed on the menu for that day. They also said that it had been enjoyable and described the members of staff as “very good cooks”. The menus were inspected. The main meal of the day is the midday meal and in the evening a light hot meal is served. An alternative meal is noted on the menu for 2 residents, when necessary. They are either vegetarians or they do not eat red meat. The menu was varied and balanced. Residents confirmed that they are involved in the menu planning. The member of staff said that depending on the mood of one of the residents, this resident sometimes cooked a meal for themselves. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents’ general health is promoted by staff that assist residents to take prescribed medication according to the instructions of the resident’s GP. Standards 18 and 19 were inspected during the previous inspection in April 2005. EVIDENCE: A resident confirmed that they were satisfied with staff helping them to manage taking their medication. Medication was stored securely and safely. Monthly blister packs were used and the tablets had been appropriately administered to residents, prior to the inspection. When bottles or tubes of medication were used the date that they had first been opened was recorded. Records were inspected and were satisfactory. The member of staff on duty confirmed that they had attended a medication training course in September 2005 and was able to describe the contents of the course. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents were confident to raise any concerns or complaints with the manager. An adult protection policy, familiarity with the interagency guidelines and protection of vulnerable adults training for staff contribute towards the safety of residents. Staff who support residents who are at risk of self-harming need policies and procedures in place to set the boundaries within which they work. EVIDENCE: There is a complaints procedure on display in the hallway, which has been amended to include the CSCI as the 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 manager said that residents’ meetings took place and that the meetings were an opportunity for residents to raise any concerns. 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, which has been amended to include details of the CSCI as the regulatory authority. The carer on duty confirmed that she had undertaken protection of vulnerable adults training in July 2005, with the manager. The need for training in adult protection procedures had been identified as a statutory requirement in the previous inspection in April 2005. No allegations or incidents of abuse have been recorded since the last 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. A statutory requirement was identified during the inspection in April 2005 that Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 15 the home has a policy in respect of a resident self-harming. The manager said that this is not yet complete. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents were satisfied that the home provided them with a comfortable place to live. Appropriate storage of belongings in residents’ rooms would promote the health and safety of residents and staff. Standard 30 was inspected during the previous inspection in April 2005. EVIDENCE: A site inspection took place. The telephone in the house that is available for residents is kept in a box, which is locked. A member of staff keeps the key to the box and the member of staff on duty said that the box is unlocked, on the request of the resident. They said that previously the telephone line had been suspended because residents have dialled 999 inappropriately and the telephone company had instructed the home to keep the telephone in a box as one of the conditions for its reinstatement. A resident had used the telephone prior to the start of the inspection on both of the visits. A resident said that the house was comfortable and that the “home blended in well” with other houses in the neighbourhood. They said that it was comfortable and in a good state of repair and that their room had all the furniture that was necessary. The Inspector saw the bedrooms, with the permission of the residents. There were a large number of bags of belongings in two of the bedrooms and in one of these rooms the bags were just inside the doorway. There were water Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 17 stains on the ceiling of the lounge where water had seeped through from the ensuite above. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35, 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. Residents’ benefit from staff that have received induction training to enable the development of good care practices. Individual supervision sessions enhance the overall support available to staff and is an opportunity to encourage personal development. Standard 34 was inspected during the previous inspection in April 2005. EVIDENCE: The carer on duty confirmed that they completed their NVQ level 2 training but they have yet to undertake mental health training. During the inspection on the Tuesday afternoon there was one member of staff on duty to support the residents, most of whom lead independent lifestyles, coming and go as they choose. 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. Residents were positive about the support provided by the manager Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 19 and the members of staff. One resident said that the manager “has done her duty as a second mother” to her and described her as “a friend”. The manager said that when recruiting new staff it was not appropriate to accept some one who did not have any previous experience relevant to working in Boniville House. The home has a policy for induction training and the forms for the 3 month and 6 month reviews were available. The manager did not know whether the content of the home’s induction training programme met the Sector Skills Council’s specification. The carer said that they were supported and supervised on a day-to-day basis and that they received individual supervision sessions. The manager said that since the previous inspection in April 2005, when a statutory requirement was identified that staff receive individual supervision sessions, four sessions have been recorded. Approximately 50 of people working in the home are agency staff and the manager said that they do not receive individual supervision sessions. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The registered manager needs to undertake training designed to develop a greater understanding of the needs of residents and the management and support of staff. There are limited systems in place for gathering feedback on the quality of the service provided by the home and the home does not have an annual development plan. Health and safety practices in the home need to promote a safe environment for both residents, staff and visitors and storage in bedrooms and adjustments needed to fire doors compromise this. EVIDENCE: The manager has not enrolled on an NVQ level 4 training course in management and care. She said that she had experienced problems in enrolling for a training course, as she was over 65 years of age. The manager said that there are opportunities for residents to give feedback about the quality of the service received during residents’ meetings and during their review meetings. The manager said that they could also speak to her when she was on duty in the home and it was noted that during the inspection Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 21 a resident came to the office to talk to the manager. The home does not have a formal system of obtaining written feedback from residents, relatives, professional visitors to the home etc and then using this information to shape the development of the service in the home. During the previous inspection in April 2005 a representative from the LFEPA carried out an inspection of the fire safety systems, equipment and procedures. The manager said that most of the requirements that had been identified have now been met although some adjustments to self-closing mechanisms on doors are still needed. During the site inspection it was noted that there were gaps under several doors where smoke could travel, in the event of a fire occurring. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 X 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Boniville House Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X X 2 X DS0000017469.V261218.R01.S.doc Version 5.0 Page 23 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 YA14 Regulation 16.2 Requirement That after consulting with residents, a programme of activities is drawn up, which provides stimulating and enjoyable opportunities for residents. (Previous timescale of 01 August 2005 not met). That the home has a policy on residents self-harming. (Previous timescale of 31 May 2005 not met). That residents’ belongings are stored away so that they do not present a fire hazard or impede entry into or exit from the bedroom. That the ceiling in the lounge is made good and redecorated. That staff have training in working with people with mental health issues. (Previous timescale of 30 April 2005 not met). That the content of the home’s induction training programme meets the Sector Skills Council’s specification. That agency staff are supported by individual supervision sessions. DS0000017469.V261218.R01.S.doc Timescale for action 01/02/06 2 YA23 12.1 01/02/06 3 YA24 23.4 01/01/06 4 5 YA24 YA32 23.2 18.1 01/03/06 01/04/06 6 YA35 18.1 01/02/06 7 YA36 18.2 01/02/06 Boniville House Version 5.0 Page 24 8 YA37 9.2 9 YA39 24.1 10 YA42 23.4 That the registered manager 31/12/06 achieves an NVQ level 4 qualification in management and care. That there is a system for 01/02/06 obtaining written feedback on the quality of the service provided from residents, relatives and professional visitors to the home. That adjustments are made to 01/01/06 the self-closing mechanisms on doors, as required. That the home seeks advice from the Fire Officer in respect of the gaps below some doors in the home and that the Fire Officer’s recommendations are implemented. 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 YA39 Good Practice Recommendations That the home prepares an annual development plan where the information obtained from quality assurance systems is used to identify the areas where change is required. Boniville House DS0000017469.V261218.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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