Inspection on 06/09/05 for Foxlands House

This inspection was carried out on 6th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Foxlands House 19/06/06

Foxlands House 11/04/05

Foxlands House 25/10/04

Foxlands House 14/07/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Foxlands House 1 Cranesbill Close Annesley Avenue, Colindale London NW9 5RQ Lead Inspector Daniel Lim Unannounced 6 September 2005 @ 09.30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Foxlands House Address 1 Cranesbill Close, Annesley Avenue, Colindale, London NW9 5DRQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8200 1796 020 8200 9610 Nigel Pink for Richmond Fellowship Gloria Achiekwelu PC Care Home only 6 beds Category(ies) of MD Mental Disorder registration, with number of places Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The homes will have one registered manager and a designated deputy manager in each home. 2. There is one male service user at Foxlands House over the age of 65 (D.O.B 24/04/1934).The CSCI must be informed when this service user no longer receives care at the home. 3. The homes Meridan House and Foxlands House will function seperately with their own registration and independent staff group to provide personal care only. Date of last inspection 11 April 2005 Brief Description of the Service: Foxlands House is a small purpose built care home which was opened in 1998. It forms part of a complex of six buildings developed on this site to accommodate people who were previously patients at Napsbury Hospital in Hertfordshire. The home is run by a charity called The Richmond Fellowship. It is registered for a maximum of six service users with mental disorders. Three of the service users may be over the age of 65 years. The stated aim of the home is to provide a home where service users can be cared for with dignity and where they can lead as independent a life as possible. The home is a detached, two storey modern house. It has six single bedrooms located on the ground and first floors. All bedrooms have ensuite facilities.The staff office, lounge, kitchen and laundry are located on the ground floor. The manager’s office and a smaller lounge is on the first floor. There is a communal bathroom and toilet on the ground floor and a second communal bathroom and toilet on the first floor. There is a small car park at the front and a garden at the back. The home is within walking distance of Colindale Hospital and about a mile away from Edgware Hospital. It is also close to shops and public transport facilities along the Edgware Road. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 6 September 2005 and took three hours to complete. The inspector found that most of the National Minimum Standards assessed had been met and the overall quality of care provided was of a high standard. During this inspection, the inspector was accompanied by the home manager (Gloria Achiekwelu) and deputy home manager (Jackie Mwaoha). The inspector was able to interview five residents independently of staff. They spoke highly of staff and indicated that they were satisfied with the quality of care provided. Three residents’ case records were examined in detail. These were comprehensive. The premises including bedrooms, communal areas and the gardens were inspected and the maintenance records were examined. Staff on duty were interviewed on a range of topics associated with their work and a sample of staff records were examined. Minutes of staff meetings and residents’ meetings were also examined. What the service does well: The care documentation examined was structured and up to date. The premises were clean and homely. The gardens were attractive. Residents had been consulted and their preferences regarding activities organised had been responded to. Residents were alert and had made significant improvement over the past year. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 6 Staff were well trained and knowledgeable regarding the care to be provided for residents. 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. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 The manager and her staff had a good understanding of the needs of residents and were able to ensure that their needs were met. EVIDENCE: Five residents who were interviewed indicated that their care needs had been met at the home and they were happy with the care provided. Comments made included, “staff are respectful”, “well cared for”, “satisfied with care”. A sample of three residents’ case records which were examined, contained plans of care and details of how residents needs had been met. The inspector observed that residents in the home were clean, appropriately dressed and appeared well cared for. The inspector further noted that residents were alert and communicative and appeared to have made significant improvement since the last inspection. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 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 standard(s) 6,7,8,9 There was evidence to indicate that residents had been consulted and encouraged to remain as independent as possible. EVIDENCE: Residents who were interviewed were able to confirm that staff listened to them and suggestions made by them had been acted upon. This included holidays and outings organised. They further informed the inspector that their preferences regarding meals provided had been responded to. The minutes of residents’ meetings were examined. These contained evidence that residents’ preferences had been responded to. The sample of three residents’ case records contained evidence that residents had been encouraged to be as independent as possible. Residents were able to confirm that they took part in some household chores such as tidying their bedrooms, assisting with cooking and watering the flowers. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,14,16,17 Residents had opportunity for personal development and the provision of meals was satisfactory. EVIDENCE: The daily life and routines of residents were well organised. The home had a varied activities programme for residents. There was evidence in the case records that they had been kept active and stimulated. The inspector was informed by residents and staff that a holiday had been organised recently for residents. Residents said they enjoyed the holiday. Outings to a safari park and other places of interest had also been arranged for residents. The daily programme and case records examined indicated that residents had been encouraged to assist in household chores such as shopping and tidying of their bedrooms. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 11 Meetings had been organised and residents had been consulted regarding the management of the home. Resident interviewed indicated that they took part in planning the menu and they were satisfied with the meals served. The menus examined appeared varied and balanced. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Most of the personal and healthcare needs of residents had been met at the home. Further improvements are needed to ensure that residents have access to the dentist and medication is stored as required. EVIDENCE: The five residents interviewed stated that they had been attended to by their GP and other healthcare staff. The medication records were well maintained and residents stated that they had been given their medication. The temperature of the medicines cupboard was at times higher than 25 degrees centigrade. The manager must ensure that the temperature is kept below 25 degrees centigrade in accordance with guidance provided by the CSCI pharmaceutical advisor. The sample of three case records contained comprehensive plans of care which addressed the holistic needs of residents. There was evidence in the records to indicate that plans prepared had been carried out. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 13 The inspector however, noted that a resident case records did not contain evidence that his dental needs had been attended to in the past year. This was discussed with the manager who agreed to make the necessary appointment with the dentist. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 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 standard(s) 22,23 There was evidence that the residents were listened to and protected from abuse and neglect. EVIDENCE: The staff records contained evidence that staff had been provided with adult protection training. The complaints book was examined and complaints made had been promptly responded to The five residents interviewed stated that they were well treated by staff and staff treated them well. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 The home was generally well furnished and well equipped, therefore providing a pleasant environment to live in. Improvements are however, needed to the bedroom of a resident. EVIDENCE: Residents interviewed stated that they were happy with the accommodation provided. The premises were found to be clean and well furnished. The hot water in bedrooms was tested and found to be within the required safe temperature range of no higher than 43 C. The gardens were attractive and seating had been provided. The inspector was informed by staff that some residents had assisted in watering the flowers in the garden. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 16 The communal areas were well furnished and appeared cosy. The required maintenance records and safety certificates were seen by the inspector. These included safety inspection certificates for the gas and electrical installations, portable appliances and fire safety equipment. One of the bedrooms inspected did not have a lockable facility. This is required to ensure that residents are able to lock away their valuables. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 The recruitment process in place ensured that residents’ needs were met by an appropriate group of staff. Staff were supported and closely supervised by their managers EVIDENCE: The deputy manager and two staff on duty were interviewed and noted to be knowledgeable regarding their role and the care to be provided to residents. The five residents who were interviewed indicated that they were well cared for and staff were pleasant and well mannered. The training records examined, indicated that staff had been provided with essential training. This included training in the care of residents who have challenging behaviour, adult protection, administration of medicines and fire safety. The staff rota was examined and staffing arrangements examined in detail. The inspector noted that a newly recruited staff had been on night duty (sleeping in). The manager explained that the staff concerned had adequate experience in her previous job. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 18 The manager further reassured the inspector that there was an on call system in place and staff (in a nearby home, Meridan) were able to provide support within minutes if assistance is required. The inspector noted that one of the residents had exhibited challenging behaviour. Therefore, for safety reasons and to ensure that residents’ care needs are attended to, a requirement is made for a risk assessment to be carried out. This assessment must be forwarded to the inspector. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,41,42 The home was well managed and systems were in place to ensure the welfare of residents and staff. Further improvements are required in the area of health and safety. EVIDENCE: When interviewed, the manager was found to be knowledgeable and residents were of the opinion that the home was well managed. There was evidence that staff and residents were consulted regarding the management of the home. Residents were able to confirm that their preferences regarding holidays, outings and meals provided were responded to. All five residents expressed satisfaction at the way the home was managed. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 20 The inspector noted that residents had made progress mentally and were alert and responsive during this inspection. In particular, the inspector noted that a resident with challenging behaviour had made progress in her mental state. Weekly fire alarm checks, fire door checks, fire drills and fire training had been documented. The inspector noted that none of the fire drills had been carried out after dark. To ensure that staff and residents are aware of the procedure to follow, at least one of the drills carried out each year must be done after dark. The inspector further noted that two windows on the ground floor did not have window restrictors. For security reasons, all windows must be fitted with window restrictors. Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 21 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 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 2 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 x 3 3 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Foxlands House Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 3 2 x 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 22 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 19 Regulation 13(1)(b) Requirement The registered person must ensure that the dental healthcare needs of residents are attended to. The registered person must ensure that medication is stored at the required temperature of no higher that 25 C The registered person must arrange for all bedrooms to be provided with lockable facilities. The registered person must review the deployment of the junior staff (identified to the manager) on the night shift.This assessment must be forwarded to the inspector.. The registered person must ensure that window restrictors are fitted to all windows on the ground floor. The registered person must arrange for fire drills to be organised at least once every three months. One of these must be carried out after dark. Timescale for action 6/11/05 2. 20 13(2) 6/10/05 3. 4. 25 32 16(2)(l) 18(1)(a) 20/10/05 13/10/05 5. 42 13(4) 13/10/05 6. 42 23(4) 1/12/05 Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 23 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 Good Practice Recommendations Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 24 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 Foxlands House 20050906 Foxlands House X00023 UN Stage 4 S10439 V244940 G59.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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