Inspection on 16/01/06 for Frays Avenue, 32

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Frays Avenue, 32 24/04/06

Frays Avenue, 32 24/08/05

Frays Avenue, 32 10/11/04

Frays Avenue, 32 04/05/04

Frays Avenue, 32 20/10/03

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

CARE HOME ADULTS 18-65 Frays Avenue, 32 West Drayton Middlesex UB7 7AG Lead Inspector Ms Pauline Griffin Unannounced Inspection 16th January 2006 11:00 Frays Avenue, 32 DS0000027069.V274114.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 Frays Avenue, 32 DS0000027069.V274114.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. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Frays Avenue, 32 Address West Drayton Middlesex UB7 7AG 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) 01895 447639 Ealing Consortium Limited Mrs Derrie Helen Evans Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered as Voluntary Small care home Main client group MH mental handicap (learning disability) Date of last inspection 24th August 2005 Brief Description of the Service: 32 Frays Avenue is a very large family house situated in a quiet residential area in West Drayton. The home is registered for three people with learning disabilities who have a high level of dependency through challenging behavioural difficulties. There are currently two male and one female Service Users and there are no vacancies. The staffing levels in the home reflect the need for one to one care at certain times and there are a minimum of two staff on duty at any time. Male staff do not provide personal care for the female Service User and the home is generally sensitive to gender issues. Service Users require two escorts for outings in the community and health related appointments. The Registered Manager is supported by a team of two Senior Careworkers (one post vacant) and seven Careworkers. The Property is owned by a Housing Association and the care staff are employed and supplied by Ealing Consortium. The home has a large comfortable lounge/dining room overlooking landscaped gardens. The Service Users bedrooms are on the first floor and are accessed by a staircase. The home is not suitable for anyone who uses a wheelchair. The West Drayton shopping centre and good public transport links to Uxbridge and the surrounding areas are within walking distance of the home. The Service User group requires the use of the homes mini bus or private cars for trips. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over one day for a period of approximately 4 hours. The home was in the process undergoing the much needed renovation work arranged with contractors by Notting Hill Housing Group who own the property. However, the noise level was so great that the front door bell could not be heard by the either of the two Staff on duty when the Inspector rang it and the door was opened by one of the builders. There were about five or six workmen in the premises, completing different tasks and there was drilling, sawing and other associated noise. The Service Users were having their lunch and did not seem too effected by the noise and activities going on in the house. However, one Service User was continually going into the front garden with the builders and wandering out of sight. There were also two other small incidents concerning this Service User that had to be pointed out to the Staff who had not noticed them. The Registered Manager was not on the premises but was contacted by telephone by the Inspector and asked to provide a plan of action as to how the Service User’s needs could be met during the time of the renovations which were expected to be for a period of six weeks. This was received by fax at the CSCI offices on the 18th January as requested. It was evident that the Registered Manager and Staff have tried to prepare for the disruption that having such extensive work carried out to the house and the impact on all concerned it would have. Service Users have been spoken to and consulted about colour schemes in their bedrooms and taken to an associated home (where similar work has been completed) to see the ‘before’ and ‘after’ look. However, the situation will need to be assessed on a daily and weekly basis and extra Staff be brought in to ensure the Service Users can be taken out (even to one of the associated homes for the day) whilst some of noisier and disruptive building activities are taking place. Builders must not have unsupervised contact with any of the Service Users. Staff must be extra vigilant for the safety and well being of those in their care during this time. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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 Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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): 3 The home has systems in place to make full assessments of prospective Service User’s needs, wishes and for setting goals for their development. EVIDENCE: There have been no new admissions to the home for over three years. A system is in place for comprehensive assessments prior to admission. There is ongoing assessment made to monitor the health, wellbeing and the development of Service Users in the home. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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 & 8 The home maintains detailed care plans that includes the Service User’s preferences and agreed targets for their development. EVIDENCE: One Service User’s file was examined and found to be comprehensive and up to date. Full background information was set out in the Client Information Sheet and Family History sheets. The Care Plan included the needs and wishes of the Service User and included risk taking, covering activities like shopping, swimming and medical appointments and the documented need for two Staff to act as escorts for such outings. The file included a section on health care appointments and outcomes, weight chart and anxiety and aggression management strategies. A monthly summary is held on file and each Service User has a 8 week review with the Keyworker and Senior Careworker. The Service User’s file included a section on finance and up to date statements of savings held. Staff were observed checking the cash held for each of the three Service Users when they had their shift handover. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 10 Service Users have a monthly meeting that concentrates mainly on the choice of meals they wish to have included in the menus. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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): 12,14,15,16 & 17 The home supports Service Users to achieve their potential in their personal development through setting targets, monitoring them and supporting their wishes within a risk management framework. EVIDENCE: Two of the Service Users do not choose to attend Day Centres on a regular basis and the third Service User chooses to attend once a week at present. The Registered Manager monitors choices like this and attendance has been found to be counter-productive for some Service Users in the past but the situation is always under review. Service Users enjoy various activities like walks to the local shops, shopping and visits to pubs and restaurants. There have been special outings in the home’s minibus and social occasions between the other two associated homes. Two members of Staff are required to accompany each of the Service Users outside the home on all occasions. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 12 Two of the Service Users were observed sitting at the dining room table, ONE making jewellery and another drawing. The third Service User moved in and out of the rooms and was waiting to go to the local shop to buy his favourite purchases. Family links are encouraged and some families visit more frequently than others. The menu of food for the week included a selection of fresh vegetables and fruit and the meals were of the type popular with the Service Users. The meal being served at the time of the inspection corresponded to the meal in the menu. Variation of choice of meal is noted in the Service User’s daily log. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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): 18 &19 Service Users are able to express their preferences as to who provides their personal care and the way it is carried out. None of the Service Users are able to control their own health care. The home manages health needs on their behalf and this is documented in the individual files. EVIDENCE: Service User’s wishes as to who provides their personal care and the manner it is performed is respected and noted in their Care Plan. Service Users have a key worker who is primarily responsible for keeping the Service User’s records up to date and ensuring that there is evidence of their preferences on file. General health care and psychiatric care is accessed through the Health Centre and included in the Care Plans. Currently, none of the Service Users needs specialist support or technical aids. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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 The home’s complaints procedure is posted in a prominent position in the hall in both formal and pictorial editions. This ensures that Service Users and their representative(s) have easy access to them. EVIDENCE: The Staff member assisting with the inspection said that there had been no complaints received about the service since the previous inspection. Leaflets were on clear display in the entrance hall to ensure that Service Users and their representative(s) have easy access to the information if they need it. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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 the following standard(s): 24,25,26, 27 & 30 The home is currently being renovated to bring the home up to a good standard of repair both inside and out. Work is expected to be completed in mid-February 2006. Whilst the work is in progress, the Service Users and Staff will experience varying degrees of disruption. Staff must be extra vigilant to ensure that Service User’s needs are met and that they are safe and well cared for during this time. EVIDENCE: Renovation is being carried out with a programme of work to improve the home both inside and out. The work requires the input from different tradesmen for things like plumbing, carpentry, glazing and re-decoration. A review of the Service Users’ needs and the Staffing numbers required must be carried out on both a weekly and daily basis to ensure safety and well being. One of the bedrooms had been re-emulsioned and a second bedroom was due to be repainted on the day following the inspection. The Staff member assisting with the inspection, said the Foreman had advised that the paint was water based and the smell should have faded by the time the Service User Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 16 went to bed that evening. However, the work had been completed by about 2pm and the smell of paint was still strong at 4pm. The bathroom and cloakroom in the home were both in the process of redecoration and out of commission. Staff said that they were using the remaining shower room with basin and toilet on the first floor to provide the Service Users with personal care. One Service User does not like to shower and he/she has been taken to an associated home to have a bath. The Registered Manager said that this Service User enjoyed this change of routine. The Staff will be challenged by the disruption of having the work carried out whilst at the same time endeavouring to maintain a level of order and cleanliness in the home. There was a mal odour in the seating area of the lounge. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 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 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): 33 Staff on duty in the home were challenged by the presence of the building workers and their responsibilities towards maintaining an effective service to the Service Users to ensure their safety and wellbeing. EVIDENCE: It was evident that the Registered Manager and Staff have tried to prepare for the disruption that having such extensive work carried out to the house and the impact on all concerned it would have. However, the situation will need to be assessed on a daily basis and extra Staff be brought in to ensure the Service Users can be taken out (even to one of the associated homes for the day) whilst some of noisier and disruptive building activities are taking place. Builders must not have unsupervised contact with any of the Service Users. Staff must be extra vigilant for the safety and well being of those in their care during this time. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 18 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): 42 & 43 During the course of the building work, Staff must ensure that all areas of daily living in the home are assessed within a risk management framework to ensure the safety and wellbeing of the Service Users. EVIDENCE: The Registered Manager must ensure that safe working practices are carried out including all the usual checks for fire equipment testing and fire drills whilst the building work is in progress. Risk assessments must be put in place to cover the challenges presenting by having the home disrupted by the building work and the building employees. Ealing Consortium are responsible for the business and financial plans for the home and the Registered Manager is responsible for monitoring the annual revenue budgets including staffing and staff training. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 19 Insurance arrangements come under the Ealing Consortium insurance policy cover for employer’s liability, public liability and medical malpractice cover. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. 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 3 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 x ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 2 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 x 33 2 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x LIFESTYLES Standard No Score 11 x 12 3 13 x 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x x x x x x 2 3 Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 21 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 YA24 Regulation 13(4)(a)(c) 23(1) Requirement Accommodation in the home including bedrooms must be in an acceptable condition and safe for the Service Users to occupy during the course of the re-furbishment. The interior decoration of the home i.e. gloss paintwork and some of the emulsion painted walls and work both inside and outside must be carried out at times when this has the least possible adverse effect on the routine of Service Users. The premises must be free from unpleasant odours. The Registered Manager must assess the need for extra Staff to be on duty particularly in view of the impact the refurbishment makes on the wellbeing and safety of the Service Users. All areas of daily living must be assessed DS0000027069.V274114.R01.S.doc Timescale for action 30/01/06 2. YA25 23(1)(a)(2)(b) 30/01/06 3 4. YA30 YA33 16(2)(k) 23(2)(d) 18(1)(a) 30/01/06 30/01/06 5. YA42 13(4)(a)(c) 30/01/06 Frays Avenue, 32 Version 5.1 Page 22 covering the areas of the home affected by building activities within a risk management framework to ensure the safety and wellbeing of the Service Users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard 27 42 Good Practice Recommendations The restricted use of bathing and washing facilities should be kept under review to ensure that Service Users are not disadvantaged by the reduction in facilities. Safety checks and fire drills must continue to be carried out throughout the course of the building and redecoration work being carried out to the home. Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Frays Avenue, 32 DS0000027069.V274114.R01.S.doc Version 5.1 Page 24 - 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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