Inspection on 24/04/06 for Frays Avenue, 32

This inspection was carried out on 24th April 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Frays Avenue, 32 16/01/06

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 24th April 2006 11.00 Frays Avenue, 32 DS0000027069.V286909.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.V286909.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.V286909.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.V286909.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 16th January 2006 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. The Registered Manager is supported by a team of two Senior Careworkers 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. Service Users require two escorts for outings in the community and health related appointments and, therefore, requires the use of the homes mini bus or private cars for trips. Frays Avenue, 32 DS0000027069.V286909.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 during the course of one day for a duration of approximately 5 ½ hours. The inspection included a tour of the building and garden, interviews with two members of Staff, interaction with the three Service Users, telephone discussions with two relatives of one of the Service Users, an interview with a visiting professional and examination of records and documents. The Registered Manager was not on duty at the time of the inspection and the Inspector was assisted by different Senior Care Staff who were on duty throughout the day. The refurbishment programme has been completed and both the exterior and interior of the home has been improved by it. The work included double glazing to all windows and French doors to the garden, new flooring, new bathroom and toilet fittings and re-decorating throughout most of the house. Staff at all levels, continue to demonstrate a high level of commitment in their care of the Service Users. Good care strategies are employed by the Staff Team for each Service User’s individual development. What the service does well: What has improved since the last inspection? The work to the exterior and interior of the home has been completed. The home has now recruited two permanent members of Staff and has achieved it’s full Staff compliment. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Frays Avenue, 32 DS0000027069.V286909.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.V286909.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): 1,2,4 & 5 The home has systems in place to make full assessments of prospective Service Users’ needs, wishes and for setting goals for their development. EVIDENCE: The Statement of Purpose contains most of the information required under the regulation. There should be reference to where the inspection reports produced by the CSCI can be accessed and the subject of confidentiality is not included. The current Service User Guide has been produced in an easy to understand pictorial format There has not been a new admission for over three years but systems are in place for comprehensive assessments of prospective Service Users. Care needs assessments on file were examined and were found to be up to date and comprehensive. The home has a contract/terms and conditions that includes all the elements of the Standard. Frays Avenue, 32 DS0000027069.V286909.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): 9 & 10 The home does an excellent job in aspects of care and Service Users are fully supported to enjoy as independent lifestyle as possible within a risk assessed framework. EVIDENCE: Care plans include good information regarding Service Users’ needs and goals. Risks are included in the assessments and the Service User and their representatives are involved in discussion to ensure that decisions are made regarding risk taking are fully considered. None of the Service Users can go out without assistance and there have been no unexplained absences at the home. One of the Service Users like to hold the key to his/her room. The home has a policy on confidentiality but this is not included in the Statement of Purpose or Service User Guide. The home is registered under the Data Protection Act 1998. Records are stored in locked cabinets and the IT system is code secure. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 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 the following standard(s): 11,13,15 & 17 The home supports Service Users and ensure their wishes and choices are taken into account. Service Users are encouraged to take part in social activities outside the home to promote their personal development. EVIDENCE: The Service Users each have a weekly programme of individual activities chosen from a selection of things they enjoy. Each of the Service Users needs two Staff to accompany them on trips outside the home but some form of excursion is arranged for each Service User every day ranging from a walk to the local shop to a day trip to the seaside. Two Service Users attend Day Centres but both prefer not to go every day. Service Users attend regular medical appointments with specialist health professionals and their general health is monitored in the home by means of things like monthly weight charts. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 11 The Senior Careworker said that one of the Service Users regularly likes to go to local pubs for meals. Other trips he/she had enjoyed recently were to London Zoo, fairgrounds, cinema and shopping in Uxbridge. Social occasions like bar be cues and parties are sometimes shared between the other two associated homes. The home has a selection of DVD’s, games and hobbies that are favourites with the Service Users. Staff had put out a DVD of ‘Who Wants to be a Millionaire?’ chosen by one of the Service Users to watch in the evening. The families of Service Users are invited to contribute to reviews and assessments. Two of the close relatives of two of the Service Users visit the home regularly. Staff were observed preparing the menu for the coming week. Each of the three Service Users have the choice for a week in turn. The menu takes the form of a notice board with pictures of the food chosen each day. The menu includes plenty of fresh fruit and vegetables as well as some interesting puddings. Variation from the menu is noted in the Service User’s daily log. Two of the Service Users have been using a fat reduced diet since last summer and have achieved a little weight loss. Service Users eat with Staff at the large dining table in the lounge overlooking the garden. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 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 the following standard(s): 18,19 & 20 Service Users are able to express their preferences as to who provides their personal care and the manner in which it is carried out. The home ensures that the Service User’s health is monitored and documented. EVIDENCE: Each Service User has a keyworker who provides the majority of their personal care. Service Users wishes as to who provides their personal care and the manner it is performed is respected and noted in the Care Plan. General health care and psychiatric care is accessed through the local Health Centre and noted in the Care Plan. None of the Service Users needs specialist support or technical aids at present. The home has systems in place for the safe administration of medication and there have been no medication errors since the last inspection. Staff provide specimen signatures and receive training from Ealing Consortium on the orqanisation’s medication administration policy. All Staff administering Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 13 medication have received up to date training. Service Users’ representatives sign a permission form to agree for the home to administer their medication. The drugs cabinet and the recording system was checked and found satisfactory. The Registered Manager said that the supply of rectal diazepam stored for one Service User would not be administered by the Staff if it were ever needed. The Registered Manager said that it had been agreed that paramedics would be summoned if the medication was required. She said that this form of medication had not been needed by the Service User for several years but it was there as a safety measure. Frays Avenue, 32 DS0000027069.V286909.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 & 23 Service Users and their representatives are confident that their views and complaints are heard and dealt with fairly and without fear of reprisal. EVIDENCE: The home’s complaints procedure is posted on the hall notice board in a prominent position. There is a leaflet in simple pictorial form and a formal complaints policy. No complaints have been received by the home in the past twelve months. No incidents or allegations of abuse relating to the Protection of Vulnerable Adults have been received by the home. The Senior Careworker said that Staff had received training in de-escalation of aggression and instances of challenging behaviour had also decreased in the past 2 years. Two Staff were observed counting the petty cash and the individual Service Users’ floats during their ‘handover’. Money and valuables are kept in a safe deposit box. Frays Avenue, 32 DS0000027069.V286909.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): 24,25,26,27,28,29 & 30 The home has received major renovation work both internally and externally and this has improved the general appearance and comfort of the environment for both Service Users and Staff. EVIDENCE: The interior of the home has been improved with new flooring, re-decoration and new curtaining. The three bedrooms were comfortable and clean with plenty of personal items. The flooring of the bathrooms and toilet floors have been replaced with a special waterproof floor covering. New bathroom suites have been installed together with tiling and fitments. Shared space in the home is roomy and comfortably furnished. The gardens have been landscaped and offer pleasant seating with plenty of space for games and bar be cues. Cabinets and bookshelves have been removed from the upstairs Staff room which has been dedicated towards a more comfortable ‘sleep in’ room. The downstairs front Staff room is now being used as an office and houses all the files and records. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 16 No mal odours were in evidence in the home. The home was clean throughout. The laundry facilities include a sluicing facility and protective clothing is available for Staff use. Frays Avenue, 32 DS0000027069.V286909.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): 31,32,33,34,35 & 36 The Service Users benefit from a well trained Staff team who receive regular supervision with the Registered Manager. EVIDENCE: The Staff structure in the home is well defined and the Registered Manager is supported by two Senior Careworkers and 7 ½ Careworkers. Two new Staff have recently been recruited and this means that the Staff complement is up to strength and there will be less need to rely on bank or agency Staff than there has been in the past. Staff sign to confirm that they have seen the home’s policies and guidance. Training records examined confirmed that Staff had received mandatory and other specialist training courses and all training was up to date. The Registered Manager has completed the NVQ level 4, two Staff have achieved level 3 and two are completing level 2. One member of Staff is an NVQ assessor. Records confirmed that Staff receive regular sessions of one to one supervision every 2/3 weeks. Staff also receive annual appraisals to review training needs and agree individual development plans. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 18 Staff files examined, confirmed that recruitment is carried out in accordance with the National Minimum Standards Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 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 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): 37,39,40 42 The home is well managed and the Service Users benefit from the open atmosphere and clear aims and objectives. EVIDENCE: Staff spoken to were able to demonstrate their knowledge and commitment to the care of the Service Users. The Registered Manager has achieved the NVQ level 4 in Care Management and records show that she undertakes regular update training in mandatory and other specialist subjects. Two types of questionnaires have been produced, one for Service Users and one for family/friends. There was no completed questionnaires or other evidence of self-monitoring available for this inspection. Feedback should be sought from professionals and other stakeholders e.g. Day Centre Staff, volunteers and health care professionals. An annual summary of monitoring carried out with action taken as a result of the outcomes must be published Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 20 and made available to Service Users/their representative(s). A copy of the summary must be forwarded to the CSCI. The home benefits from a set of comprehensive policies and guidance produced by Ealing Consortium and these are under regular review. Staff receive training and update training in Health and Safety arranged by Ealing Consortium. Records of training confirmed that mandatory training was up to date. However, moving and handling training is only being provided every three years when the Nationally accepted frequency is annually. There were no areas of risk identified in the home during the course of the inspection. Records were examined for regular checks on fire safety equipment, water safety, gas boiler, electrical appliances, fridge/freezer temperatures. The home has a house maintance log, clinical waste collections and fire drills are carried out at regular intervals (the last one on 21/4/06). Each Service User is assessed for their ability to evacuate the premises in the event of an emergency such as fire. Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 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 Standard No Score 1 3 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 x 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x 3 2 LIFESTYLES Standard No Score 11 3 12 x 13 3 14 x 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 2 3 x 2 x Frays Avenue, 32 DS0000027069.V286909.R01.S.doc Version 5.1 Page 22 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 YA39 Regulation 24 Requirement Timescale for action 21/08/06 2. YA42 18(1) a & c (i) The outcomes and summary of the quality monitoring system must be produced. A copy of the report must be made available to Service Users/representative(s) and a copy sent to the CSCI. Staff must receive update 21/08/06 training at appropriate intervals in mandatory Health and Safety subjects with particular emphasis on moving and handling. 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 YA10 Good Practice Recommendations The subject of confidentiality should be included in the Statement of Purpose and Service User Guide. Frays Avenue, 32 DS0000027069.V286909.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.V286909.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. 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