Inspection on 24/08/05 for Frays Avenue, 32

This inspection was carried out on 24th August 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Frays Avenue, 32 24/04/06

Frays Avenue, 32 16/01/06

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 32 Frays Avenue West Drayton Middlesex UB7 7AG Lead Inspector Pauline Griffin Unannounced 24 August 2005 10.30 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. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 3 Frays Avenue Address West Drayton, Middlesex UB7 7AG 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) 01895 447 639 derrie3@aol.com Ealing Consortium Ltd Mrs Derrie Helen Evans Care Home 3 Category(ies) of Learning Disability (3) registration, with number of places 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 10TH November 2004 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 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 are within walking distance of the home. The Service User group requires the use of the home’s mini bus or private cars for trips. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out in the course of one day for a period of 5 hours. The inspection included the examination of records and document, interviews with two Staff and two Service Users and a tour of the premises. The Registered Manager was on annual leave at the time of the inspection and the inspector was assisted by the Senior Careworker. The exterior decoration of the building had still not been improved and the paintwork and general appearance of the property remains below the level of neighbouring properties in the avenue. The Service Users continue to show improvement in behaviour and skills. This is due to good care strategies employed by the Staff team for the Service User’s individual development. What the service does well: What has improved since the last inspection? One Service User has an improved vocabulary and instances of challenging behaviour have reduced. Successful recruitment of permanent Staff members means the home no longer relies so heavily on agency Staff members. The number of accidents and incidents have reduced. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 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. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.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 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.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 & 5 Service Users benefit from a full assessment of their needs that takes into account their needs, wishes and sets goals for their development. EVIDENCE: There have been no new admissions to the home for over three years but a system is in place for comprehensive assessments to be made prior to admission. The home has a contract/terms and conditions that includes all the elements of the Standard. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.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) 6,9 & 10 Service Users benefit from a detailed Care Plan that sets out the aims and objectives of their care package and includes targets and risk management. EVIDENCE: One Care Plan was examined and was found to be up to date and comprehensive, setting out the full details of the background, needs, wishes and goals of the individual Service User. Risk taking was included in the Care Plan to cover activities like shopping, swimming and medical appointments. The home has a policy on Confidentiality and is registered under the Data Protection Act 1998. Records are stored in lockable cabinets and the IT system is code secure. Service Users were treated with respect and kindness at all times during the course of the inspection. The Staff and Service Users related in a relaxed and comfortable manner and were observed to be completing a jigsaw puzzle, drawing and making jewellery. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.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) 13,15 & 17 The home supports the service users to achieve their potential in their personal development through setting targets and supporting their wishes within a risk managed framework. EVIDENCE: The Senior Careworker said that Service Users enjoy trips out for shopping, meals and events. However, she said that using public transport and being in overcrowded places needed a risk assessment. The home has it’s own transport available. The Senior Careworker said that one of the Service Users liked to visit the local pubs and cafes. The group had enjoyed a trip to Brighton recently, visited a bowling alley and had a barbecue in the garden. Two Staff are required to accompany Service Users outside the home on all occasions. Family links are encouraged by the Home with some families visiting more frequently than others. Two of the Service Users attend day centres on one day per week. The Senior Careworker said that the third Service User did not 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 11 attend a day centre at present because it had been assessed that it was counter-productive in the overall development. Well balanced meals are offered in the Home with Service Users having the opportunity to choose from a selection of their favourites at the weekly meetings where they pick the menu for the week ahead. Choice is only restricted by dietary considerations. Staff note variation of choice in the Service User’s daily log. Service Users eat with Staff at the large dining table in the lounge overlooking the gardens. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.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) 20 & 21 The home has a satisfactory medication policy and system of administration. All Staff responsible for medication have received appropriate training to ensure that they understand their responsibilities and administer in accordance with the home’s policy and guidance. EVIDENCE: The Senior Careworker said that all Staff had now received training in administration of medication provided by Ealing Consortium. There was no evidence, however, that the Registered Manager or Senior Careworker had received training. All Staff involved in the administration of medication are providing specimen signatures. One Staff member from the ‘reserve bank’ administers medication and has received training. The recording system was examined and found to be satisfactory. The drugs cabinet was checked and also found to be satisfactory. One Service User had been helped by his/her family to fill in the home’s questionnaire for ‘When I am Dead’ that is part of Ealing Consortium’s policy on death and dying. The policy aims to ensure wishes are respected regarding death and illness. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 13 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 Service Users and their representatives are confident that their views and complaints are heard and dealt with fairly without fear of reprisal. EVIDENCE: The home’s Complaints procedure was not in clear view on the main pin board where it is usually placed. The Senior Careworker was not sure if Service Users or their representatives have an up to date Service User Guide that includes the complaints procedure. The complaints log showed that no complaints had been received since the previous inspection. No incidents or allegations of abuse relating to the Protection of Vulnerable Adults had 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 further decreased since the training. Two Staff were counting the Service Users cash at the ‘handover’ and both signed for it. The cash is kept in separate pouches and stored in the home’s safe deposit box. The three Service User’s financial records tallied with the cash held for them. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 14 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) 24,26,27 & 30 The decorative order of the home remains below standard. The external repair and appearance of the house falls below those of neighbouring properties. There are areas inside the home that do not provide people living there with a homely environment that is clean and comfortable. EVIDENCE: The external paintwork and repair of the property has been the subject of Recommendations and Requirements in every inspection carried out since 2002 and no progress has been made. The downstairs cloakroom toilet is in poor condition. Wall tiles have been painted over and this paint is now flaking badly. The floor covering is stained. There are damp patches along the skirting area and the radiator cover is showing signs of mould and distortion at floor level. • The gloss paintwork on the stairs, doorframes and skirting boards is chipped, dirty and sticky to the touch. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 15 • In one of the bedrooms there was a mal odour. The paintwork in the room needs attention and the net curtains were discoloured and falling down. A double electrical socket was smashed. The net curtains in the front room of the house are discoloured and need laundering and re-hanging. • 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 16 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 & 36 The Service Users benefit from a well trained staff team who receive regular supervision sessions with the Registered Manager. EVIDENCE: Staff sign to confirm that have seen the home’s policies and guidance. The Senior Careworker was able to confirm that the staff structure of the home was clear and responsibilities well defined. The Registered Manager is supported by two Senior Careworkers (one vacancy) and seven Careworkers. The Registered Manager has completed the NVQ level 4. There are currently 3 Careworkers who have completed NVQ level 2/3 and 2 Staff are commencing NVQ level 2 in September 2005. The Senior Careworker said that Staff receive specialist training and was able to produce evidence of the courses and dates undertaken. The Senior Careworker said that Staff received regular one to one supervision every 2/3 weeks and this is in compliance of the National Minimum Standards (NMS) that recommends six sessions of supervision per annum. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 17 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 & 42 The home is well managed and the Service Users benefit from the open atmosphere and clear aims and objectives. EVIDENCE: Motivation in the home is high and the Senior Careworker spoke with enthusiasm about the progress made by the Service Users in the past 12 months. The Staff receive training in Health and Safety arranged by Ealing Consortium and all Staff receive first aid and food hygiene training as part of their induction course. There were no areas of risk identified during the course of the inspection. Records were examined of checks on fire safety equipment, fire drills, accident reporting, risk assessments, kitchen maintenance, fridge/freezer temperature checks, house maintenance log, clinical waste disposal, medication and Service 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 18 User’s money. The LFEPA (London Fire and Emergency Planning Authority) visited the home in 2003. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 19 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 x x 3 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 2 1 x x 2 Standard No 11 12 13 14 15 16 17 x x 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 3 Frays Avenue Score x x 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 x G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 20 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 24 Regulation 23(1)(a)( 2)(b)(d) Requirement The Registered Manager/Registered Person must ensure the upkeep of the exterior of the premises is maintained and that the home is in good general repair This is restated from previous inspections during the past two years. The Registered Manager/Registered Person must ensure that the downstairs toilet be renovated to a safe and presentable standard. This is restated from previous inspections during the past two years. The interior decoration of the home i.e. gloss paintwork and some of the emulsion painted walls and fixtures and fittings require attention. The premises must be free from unpleasant odours. All Staff administering medication must attend an accrediated training course prior to this. Timescale for action 10/01/06 2. 24 23(1)(a)( 2)(b)(d) 10/01/06 3. 24 23(1)(a)( 2)(b)(d) 10/01/06 4. 5. 30 20 23(2)(d) 3(2) 10/01/06 30/09/05 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 21 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 22 Good Practice Recommendations Service Users and their representatives should have access to a copy of the complaints procedure and be given the reassurance that making a complaint or query will not result in any type of reprisal. 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor 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 3 Frays Avenue G61-G10 s27069 Frays Ave v214320 240805 Stage 4.doc Version 1.40 Page 23 - 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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