Inspection on 09/05/06 for Boniville House

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 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 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 08/07/2008.

CARE HOME ADULTS 18-65 Boniville House 17 Melrose Avenue London NW2 4LH Lead Inspector Julie Schofield Key Unannounced Inspection 9th May 2006 09:15 Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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.V289591.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 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 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.V289591.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 visits to the home, as the registered manager was on annual leave at the time of the first visit. The first visit commenced at 9.15am on the 8th May 2006 and finished at 11.45am. The second visit commenced at 9.30am on the 22nd May 2006 and finished at 3.05pm. The Inspector would like to thank the manager, staff and residents for their comments during the inspection visits. In addition to discussions the inspection also included a site visit, examination of records and observations of the care practices in the home. What the service does well: What has improved since the last inspection? Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 6 A number of statutory requirements were identified during the previous inspection and there is now compliance. A programme of activities has been drawn up, after consulting residents during a residents’ meeting. The manager has drawn up a policy on how to support residents who may self-harm. Residents have been encouraged to store their belongings away from the doorway of their room so that the belongings do not present a health and safety hazard. The ceiling in the lounge has been made good and redecorated. The induction training programme for staff has been redesigned and new record forms introduced. The induction training programme meets the Sector Skills Council’s specification. All staff in the home, including agency staff, are supported by individual supervision sessions. Quality assurance forms have been drawn up for use with residents, relatives and professional visitors to the home. The Fire Officer has visited the home and is satisfied with the efficiency of the fire doors. What they could do better: Care plans need to be reviewed on a regular basis, either by the home or by the placing authority as part of a review meeting. Residents must sign the copy of their care plan, if possible, to signify that they were involved in the process and are part of the agreement over the support required. Risk assessments must be reviewed on a regular basis. Encouragement is needed for residents to take part in the activities, which they have chosen to be included in the weekly programme. All significant events, which affect the well being of the resident, must be reported to the CSCI and if an allegation is made by a resident that they have been assaulted by another resident a referral needs to be made to the Adult Protection team. Any training of staff in respect of restraint needs to be given by an accredited trainer. In terms of the environment a programme of decorating the residents’ bedrooms is needed. One of the bedroom carpets needs to be cleaned or replaced, lampshades and doorstoppers installed as necessary, a crack and peeling paint in the bathroom made good and redecorated, scuffed paint on the walls of the dining room made good and redecorated and dining chairs repaired or replaced. The washing machine must be repaired. Staff working in the home all need to have undertaken training in mental health issues and the home needs a training plan. Product information needs to be available for all items that are stored in the COSHH cupboard. The individual record sheets in the accident book need to have information recorded in all the boxes. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 7 The recruitment process must include verification of the identity of the applicant. The date on which the CRB was returned needs to be recorded so that the validity of the form can be demonstrated. When agency staff are used in the home the manager must obtain written confirmation from the agency that all the necessary references and checks have been received. The manager must complete her RMA training. The quality assurance questionnaires that have been developed need to be distributed and the information obtained then used to draw up a development plan for the service. Recommendations made as a result of this inspection include assisting a resident to obtain a copy of the minutes of their review meeting, convened by the placing authority. It is also recommended that participation in activities is recorded on activities sheets and a note is made if a resident chooses to do nothing. More variety between weekly menus should be introduced. The marks made by cigarettes on the fingers of a resident should be monitored and staff should continue to encourage residents to attend their health care appointments. The throws over the settees in the lounge could be replaced by more attractive ones and the Christmas decoration removed from the light fitting. Bedrooms should be aired during the day, weather permitting. A box could be provided for the return of quality assurance forms to protect the anonymity of the resident. When the individual accident record form is complete it should be detached and placed in the clients file, after the reference number has been recorded on the counterfoil and the form. 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.V289591.R01.S.doc Version 5.1 Page 8 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.V289591.R01.S.doc Version 5.1 Page 9 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): None of the standards were inspected during this inspection as no new resident has been admitted to the home during the previous 12 months. EVIDENCE: Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Comprehensive care plans have been drawn up for each resident so that the service provided can meet the individual needs of the resident. Without a system in place for formally reviewing care plans on a regular basis the home is unable to demonstrate that changes in the needs of residents are identified and addressed. The resident’s right to make decisions about their life in the home is respected. Responsible risk taking contributes towards the resident leading an independent lifestyle, although a regular review of risk assessments is needed to ensure that the changing needs of residents are identified and addressed. EVIDENCE: Three case files were inspected and it was noted that each file contained a care plan which included an assessment of personal, social and health care needs. It was recorded that residents had received a copy of their care plan but residents did not sign the copy of the plan, which is kept on file. The regularity of review meetings (convened either by the home or by the placing authority) Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 11 was studied and it was noted that meetings did not take place at least twice per year. The manager said that the placing authority has arranged 2 review meetings for the 24th May 2006 and that a review meeting was held recently, on the 4th April. Another resident had their review meeting last year and the fifth resident did not come back to the home when their meeting was scheduled to take place in May. When asked about review meetings, 3 of the residents said that they could not remember a recent meeting with their social worker and 1 resident said that they were still waiting for a copy of the minutes of the meeting to be sent to them. During discussions with residents examples were given about decision making and having choice within their life in the home. Examples included being able to go out as they pleased, get up in the morning and go to bed when they wished, spend time in their room without staff intrusion, wear what they want, eat what they want and to take part or not take part in activities. Residents confirmed that they had control of their finances and that they chose how they spent their money. Some residents were responsible for drawing money out of their accounts although one resident said that they had been advised not to draw large amounts of money, after some of their money had been stolen on their journey back to the home. Although the manager is not the appointee for any resident she is responsible for passing on money to 2 residents. The account books for recording these transactions were inspected and were satisfactory. It was noted that the resident signed to acknowledge the receipt of money. Case files contained risk assessments, which were tailored to the individual needs of residents. The risk assessment included an identification of the risk, the level of risk and the action required to minimise the risk. Risk assessments had been completed for independently using community facilities, smoking, violent outbursts etc. The forms were dated 2004 and there was no evidence that they had been subject to review. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15, 16, 17 Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Taking part in activities and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle although staff need to encourage residents to participate in activities offered in the home. Residents are encouraged to maintain contact with their families, to establish relationships and to observe their religious practices so that their social and spiritual needs are met. Residents are encouraged to become more independent by making decisions and by having their wishes respected. Residents are offered a balanced diet to promote their well being and the diet respects their religious and cultural needs. EVIDENCE: None of the residents is in employment although referrals were made to Qest. A representative called to the home to speak to the residents and 1 resident expressed interest in being helped to find employment. However, the resident later changed their mind. One resident attends a day centre, when they wish. Other residents follow their own interests. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 13 Residents gave examples of their use of community resources and facilities. They were pleased with the location of the home, which gave them easy access to shops and to public transport. They also used pubs, cafes, restaurants and religious centres. Residents were asked about the local elections that took place the previous week. Although residents confirmed that they had received polling cards they had declined to vote. It was noted during the inspection that residents left the home to go out shopping or to go to the hairdressers etc. Residents are able to leave and to return to the home when they please, although they are encouraged to let the member of staff on duty know of their movements. A discussion took place with the member of staff on duty about a statutory requirement identified in the previous inspection report. This was in respect of activities. She confirmed that a weekly activities programme had been drawn up, after a meeting where residents had been asked for their ideas and suggestions. Individual records (activity sheets) are kept of how residents spend their time. Each sheet has pre-recorded sessions on Monday, Wednesday and Friday mornings where the resident tidies and cleans their room. Recent activity sheets were examined and it was noted that not every morning or afternoon session was completed. Those that had entries were about going to the bank/post office, going to the GP, going shopping, going out with a friend, reading or watching TV. They did not confirm that any of the weekly activities organised by the staff on duty were taking place. The manager said that residents had declined to go away on holiday in 2005. Four of the residents have a relative or friend where contact is maintained. One resident visits their relative and the other residents receive an occasional visit from their relative. A resident said that they telephone their relative from time to time and another resident exchanges letters with their family member. One resident said that they are supported by a member of a befriending scheme, organised by Brent Mind, and that the person meets them on a weekly basis. Sometimes they go out for a coffee or the person visits them at Boniville House. It was observed that residents are encouraged to be independent and to follow their individual lifestyles. Residents’ rights are respected and staff knock on the resident’s bedroom door if the resident is in their room and the member of staff wishes to speak to them. The member of staff waits before entering until they are invited to come in. Residents are provided with keys to both the front door and to their bedroom door. Residents choose whether they wish to spend time with others or whether to enjoy the privacy of their room. They have access to the communal areas in the home, including the garden area. A discussion about the menus took place with residents and staff. Two residents confirmed that they were involved in the menu planning and that one of the residents wrote the menu out each week. Menus were available for Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 14 inspection and it was noted that there were only small differences to the menu from week to week. The menu recorded alternatives for individual residents and on one day 3 different lunches were recorded. Two residents sometimes prefer a vegetarian option. One resident is a Hindu and the foods offered meet the resident’s cultural and religious needs. The menu did include different food groups and residents confirmed that it included their favourite foods. The main meal was served at lunchtime and there was a lighter option for the evening meal. A resident confirmed that they were able to choose an alternative meal if they wished and they said that they had helped the member of staff prepare scrambled eggs on toast the previous evening. Residents confirmed that the staff on duty were good cooks and that portion sizes were plentiful. Training records demonstrate that members of staff have undertaken food hygiene training. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive prompting with personal care in a manner, which respects their privacy and dignity. Residents’ health care needs are met through access to health care services in the community. Residents’ general health and well-being is promoted by staff that assist the resident to take prescribed medication in accordance with the instructions of the resident’s GP EVIDENCE: Residents are self-caring although they may need prompting from staff to maintain a good standard of personal hygiene. The manager said that residents are encouraged to follow a regular programme of bathing and to change their clothing on a regular basis. Residents choose what they wish to wear each day. One resident said that went to the hairdressers on a regular basis and had an appointment for later in the day. Male and female carers are employed in the home. The home has a system of key workers for residents. Whilst speaking with a resident it was noted that the resident had marks on the skin between their fingers. The resident confirmed that these were as a result of smoking and although the marks looked red and raw the resident said Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 16 that they did not hurt. The resident also said that they usually covered these with plasters but the plasters kept falling off. One resident said that they had lost some weight but that they were pleased with this, as it had reduced their cholesterol level, which had been above the safe limit. (The manager said that residents were encouraged to follow a pattern of healthy eating). The resident confirmed that the staff in the home helped them to monitor their weight. Monthly weight charts for each resident were available for inspection. Residents discussed health care appointments and confirmed that they appreciated that a member of staff accompanied them on outpatient appointments. They chose whether they wished to see the optician, dentist, chiropodist etc and some regular appointments took place. Residents also confirmed that they had access to routine health screening e.g. blood tests. They said that they had declined to have a flu jab. When examining case files it was noted that decisions had been taken by health care professionals about the continuing need for CPA meetings, OPD meetings and reviews by the psychiatrist. The manager said that she has contacted them to voice concerns over decisions when she has observed deterioration in the mental health of a resident. Medication was stored securely and safely. Monthly blister packs were used and the blisters that had been opened prior to the inspection corresponded with the records. The administration of medication to a resident was observed and it was noted that a large spoon was placed underneath the blister to prevent tablets from falling onto the table or floor. The resident preferred to swallow each tablet individually, without water, and then to take a drink after they had swallowed all the tablets. Records were up to date. Records are signed after the administration and so the medication for a resident that was having breakfast a little later was still in the blister pack and the records for this resident were still to be signed. The member of staff on duty confirmed that they had attended a medication training course and she has previously discussed the content of this course with the Inspector. One resident commented that the amount of medication that they took had been decreased. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Overall quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. However when an allegation is made it must be referred both to the adult protection team and to the social worker to ensure that the resident is able to feel “safe”. EVIDENCE: A complaints policy is in place in the home. It includes the stages in the process and timescales for each stage to be completed. It refers the complainant to other agencies e.g. the Ombudsman, the local authority and the CSCI. The manager said that no complaints have been recorded since the last inspection. Residents confirmed that if they had a complaint they could speak to a member of staff or to the manager. A statutory requirement was identified during the previous inspection that the home has a policy on residents self-harming. The manager has developed a policy and this was available for inspection. It included a definition of selfharm, an explanation of the causes behind self-harming and they ways in which staff can support residents who self-harm. A protection of vulnerable adults procedure is in place in the home. The manager and staff have undertaken protection of vulnerable adults training. The manager said that no allegations or incidents have been referred to the adult protection team although a resident has accused another resident of assault. There were no Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 18 witnesses to the alleged assault and the resident declined to report the matter to the police, although hospital treatment was required. The manager reported the allegation to the social workers and a copy of the letter was available for inspection. It was not reported to the CSCI. The need to refer an allegation to the adult protection team was discussed with the manager. The manager said that she gives training to the staff team in respect of restraint. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a home where some repairs and redecoration are required to maintain a comfortable level of accommodation. Residents live in a home where standards of cleanliness are satisfactory although the repair of the washing machine is needed to encourage residents to regularly wash and change clothing. EVIDENCE: A statutory requirement was identified during the previous inspection that the ceiling in the lounge is made good and redecorated. This has been done. A statutory requirement was identified during the previous inspection that residents’ belongings are stored away so that they do not present a fire hazard or impede entry into or exit from the bedroom. The manager said that this had been discussed with resident and belongings are stored against a wall so that entering or leaving the room is not hampered. However the resident wishes to keep all the belongings. During the site visit it was noted that a programme of redecoration for the residents’ bedrooms was required. The bedroom on the second floor, the bedroom on the first floor (adjacent to the Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 20 laundry room) and the bedroom on the ground floor (with a patio door to the garden) to be given priority as there were marks on the walls. The carpet in the bedroom on the second floor was stained near the bed. Two bedrooms needed lampshades for the light fittings suspended from the ceiling. One bedroom needed a doorstop fitted to the skirting board to prevent the door handle gouging a hole in the wall when the door is flung open. There was a crack in the plasterwork and some flaking paint on the wall of the first floor bathroom. The settees in the lounge were covered with throws, which looked drab, and a Christmas decoration was attached to the chandelier light fitting. The paint was scuffed where dining chairs had rubbed against the wall and the top part of the back of 2 of the dining chairs was missing. All other parts of the home, the décor, the furniture and furnishings were satisfactory. During the site inspection it was noted that the home was clean and tidy. However bedrooms need to be aired to prevent a stale smell developing. Training records demonstrated that staff have received infection control training. The laundry room was inspected. It was noted that the washing machine had stopped during the spin cycle and the manager informed a resident that had come to use the laundry room that she would call out a service engineer to repair the machine. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff working with residents who have mental health problems need specific training that will enable them to provide support, which is based on knowledge, and understanding. However the general skills and knowledge of carers is enhanced by NVQ training and residents benefit from this. The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. Recruitment practices, which include checks and references, protect the welfare and safety of residents and the home needs to ensure that proof of identity is part of the process and that the process has been applied to all members of staff. An induction training programme is in place for staff to demonstrate that they have the skills and understanding necessary to meet the individual needs of residents. Supervising and supporting staff helps the manager to monitor the quality of service provided to the residents. EVIDENCE: A statutory requirement was identified during previous inspections that staff have training in working with people with mental health issues. The manager said that 2 of the 4 carers working in the home have received training in respect of mental health issues and there were training certificates available for inspection. The member of staff on duty during the first visit said that they Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 22 had not yet received this training. Two of the 4 carers have completed their NVQ training. One member of staff had completed their level 2 training and the other member of staff had completed their level 3 training. The home has met the target of 50 of carers achieving an NVQ level 2 or 3 qualification. A copy of the rota for May 2006 was available for inspection. As the manager was on annual leave no hours were recorded for her for the month. The home was maintaining agreed staffing levels. There is a minimum of 1 member of staff on duty in the home, at all times. Residents praised the manager, and individual members of staff by name, for the quality of the service provided. Two staff have been employed in the home, since the last inspection and their staff files were examined. Each file contained an application form, a declaration of health, evidence of an enhanced CRB application being obtained (but not the date on which it had been returned) and 2 satisfactory references. One of the files did not contain evidence of proof of identity. Another member of staff working in the home is supplied by an agency, although there is no written confirmation from the agency that all the checks and references have been undertaken. A statutory requirement was identified during the previous inspection that the content of the home’s induction training programme meets the Sector Skills Council’s specification. The manager has recently attended a training course on induction training for carers, her attendance certificate was available for inspection, and has drawn up a new induction training programme and induction record. The manager was satisfied that these meet the specification. The new documents were available for inspection. The home does not have a training plan, which addresses the aims of the home and the changing needs of the residents. A statutory requirement was identified during the previous inspection that agency staff are supported by individual supervision sessions. The manager said that she is giving individual supervision sessions to each member of staff and that these are given approximately every 2 months. Staff files contained supervision record forms. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to complete her RMA training as continuing to develop knowledge and skills contributes towards an effective manager who is aware of the needs of residents and staff. Quality assurance questionnaires help to monitor the service provided to residents and contribute towards the development of the service. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents. Regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. Members of staff need product information for the safe use of hazardous substances. If accident records were complete this would assist the manager in monitoring health and safety conditions in the home. EVIDENCE: The manager registered for the RMA with a training company and began the course. Unfortunately the training company has ceased trading and the Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 24 manager is arranging to register with another company. Over the last 12 months the manager has attended a training course in respect of the induction of new carers, developing staff through communication and a learning disabilities and mental health training course. A statutory requirement was identified during the previous inspection that there is a system for obtaining written feedback on the quality of the service provided from residents, relatives and professional visitors to the home. A discussion took place with the manager and the forms that have been drawn up for use with residents, with relatives and with professional visitors e.g. social workers were available for inspection. It is intended that the residents’ forms will be distributed at the next residents’ meeting and it was suggested that a collection box be used for their return so that a resident who wishes to remain anonymous may do so. Questionnaires for residents include questions about the quality of care, staff support, food, activities, basic values (privacy, dignity, independence) and safety. The manager said that the relatives’ forms would be given to them when they next visit the home, or if their visits are not regular the form will be sent to the relative. Two review meetings are to be held soon and the manager intends to use these meetings to give a feedback form to the representative of the placing authority. The manager said that the information would be used when drawing up a development plan for the home. A statutory requirement was identified during the previous inspection 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. The manager has spoken to the Fire Officer who has visited the home and he is satisfied that the gaps do not compromise the safety of those living, working or visiting the home. Training records confirmed that staff had received training in safe working practice topics i.e. infection control, manual handling, first aid, fire safety and food hygiene. Certificates were available to demonstrate that fire precautionary equipment and systems within the home are checked and serviced on a regular basis. A record was kept of regular fire alarm tests and fire drills. There were recorded risk assessments for fire safety, health and safety and legionella. Hazardous products were stored in a locked COSHH cupboard but product information was not available. The accident book was inspected. Pages had been left in the book and one of these pages had not been fully completed. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 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 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15.2 Requirement That care plans are reviewed at least on a 6 monthly basis. (Either the home or the placing authority can convene the reviewing meeting). That the resident signs their care plan. That risk assessments are reviewed on a regular basis and that a record is kept of the review. That staff encourage residents to take part in any activities in the home, if the residents wish, and regularly review, with residents, the range of activities offered. That if a resident alleges that another resident assaults them; the manager contacts the adult protection team. That all significant events in the home e.g. events which require a resident to seek hospital treatment or incidents that are reported to the adult protection team are reported to the CSCI. That an accredited trainer delivers training in restraint, if this is identified as a training need for the staff team. DS0000017469.V289591.R01.S.doc Timescale for action 01/09/06 2 3 YA6 YA9 15.1 13.4 01/07/06 01/08/06 4 YA14 16.2 01/07/06 5 YA23 13.6 23/05/06 6 YA23 37.1 23/05/06 7 YA23 13.7 01/09/06 Boniville House Version 5.1 Page 27 8 9 10 YA24 YA24 YA24 23.2 23.2 23.2 11 YA24 23.2 12 YA24 23.2 13 14 YA30 YA32 16.2 18.1 That residents’ bedrooms are decorated. That the carpet in the second floor bedroom is cleaned or replaced. That lampshades are provided for the ceiling light fittings in 2 of the residents’ bedrooms and that a doorstopper is provided in the room where there are gouges in the wall. That the crack in the plasterwork and the flaking paint in the ground floor bathroom are made good and redecorated. That the scuffed paintwork in the dining room, where the backs of dining chairs have rubbed, is made good and redecorated. That the top part of the back of 2 of the dining chairs is repaired or the chairs are replaced. That the washing machine is repaired. That all staff have training in working with people with mental health issues. (Previous timescale of 30 April 2005 and 1st April 2006 not met). That the recruitment process includes verification of the identity of the applicant. That confirmation, in writing, is obtained from the agency that the checks and references have been carried out as part of the agency’s recruitment policy. That the date on which the CRB disclosure is returned is recorded, as CRB disclosures are not portable from one employer to the next. That a training plan is developed, which addresses the aims of the home and the changing needs of the residents. DS0000017469.V289591.R01.S.doc 01/12/06 01/09/06 01/08/06 01/08/06 01/08/06 12/06/06 01/10/06 15 16 YA34 YA34 19.1 19.1 01/07/06 12/06/06 17 YA34 19.1 01/07/06 18 YA35 18.1 01/09/06 Boniville House Version 5.1 Page 28 19 YA37 9.2 That the registered manager achieves an NVQ level 4 qualification in management and care. 31/12/06 20 YA39 24.1 21 YA42 13.4 22 YA42 17.2S3.3 That the newly developed quality 01/09/06 assurance forms for residents, relatives and professional visitors to the home are distributed at the earliest opportunity. That this information is collected, analysed and used in the formation of a development plan for the home, which responds to the changing needs of residents. That product information is 01/07/06 obtained for all hazardous products that are stored in the COSHH cupboard. That when an entry is made in 12/06/06 the accident book all the details are recorded on the sheet. 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 4 5 6 Refer to Standard YA6 YA14 YA17 YA19 YA19 YA24 Good Practice Recommendations That residents are supported to request a copy of the minutes of their review meeting (convened by the placing authority). That activities sheets are complete and up to date and if no activities are engaged in this is recorded on the sheet. That residents are encouraged to introduce more variety between the weekly menus. That staff monitor the burns on the inside of the resident’s fingers (caused by smoking) and encourage the resident to seek medical assistance, as appropriate. That staff encourage residents to maintain a programme of regular health care appointments. That the throws covering the settees in the lounge are replaced and that the Christmas decoration attached to the chandelier light fitting is removed. DS0000017469.V289591.R01.S.doc Version 5.1 Page 29 Boniville House 7 8 9 YA30 YA39 YA42 That residents are encouraged to air their rooms during the day, weather permitting, to prevent the build up of stale odours. That a collection box is used for the return of the residents’ quality assurance forms so that if they wish to remain anonymous, they may do so. That when each individual record sheet is completed in the accident book a reference number is recorded on both the counterfoil and on the record sheet e.g. the initials of the resident and the date on which the accident occurred and then the record sheet is detached from the book and placed in the resident’s case file. Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Boniville House DS0000017469.V289591.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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