Inspection on 13/02/06 for Mayfair Avenue

This inspection was carried out on 13th February 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfair Avenue 25/07/07

Mayfair Avenue 26/08/06

Mayfair Avenue 10/02/05

Mayfair Avenue 19/08/04

Mayfair Avenue 27/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Mayfair Avenue 29 Mayfair Avenue Whitton Middlesex TW2 7JG Lead Inspector Sandy Patrick Unannounced Inspection 13th February 2006 9:30 Mayfair Avenue DS0000017383.V261231.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 Mayfair Avenue DS0000017383.V261231.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. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mayfair Avenue Address 29 Mayfair Avenue Whitton Middlesex TW2 7JG 020 8715 5920 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) Richmond Homes for Life Trust Mrs Sarah Jane Baron Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2005 Brief Description of the Service: 29 Mayfair Avenue is a care home for four service users who have a learning disability. The home is owned and managed by Richmond Homes for Life Trust, a small non-profit making organisation providing accommodation and support in the London Borough of Richmond. The home is situated in a residential road in Whitton, close to the high street, transport links and leisure facilities. The Registered Persons have produced a Statement of Purpose, which includes information on the aims and objectives of the service. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the Inspector found during the inspection. The inspection took place on 13th February 2006, and was unannounced. The Registered Manager left earlier in the month. The new Manager was present throughout the inspection. He previously worked as a Deputy Manager in another of Richmond Homes for Life’s homes, and had been working at Mayfair Avenue for about a month. The Inspector met with all of the service users. Three service users went out for the day shortly after the beginning of the inspection. Service users appeared happy and relaxed at the home and the staff on duty treated them with kindness and respect. What the service does well: What has improved since the last inspection? Considerable work has gone into meeting requirements made at the last inspection. The service users have made individual achievements. The organisation has started work on a DVD Service User Guide for the home. The service users have been given new licence agreements, which contain photographs and pictures to help explain the information. The staff have reorganised service users’ files so that information is more accessible. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 6 The staff have assessed risks and recorded these. The home is now fully staffed and has a new Manager. 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. Mayfair Avenue DS0000017383.V261231.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 Mayfair Avenue DS0000017383.V261231.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&5 The organisation is working on a DVD guide to the home which will be available to existing and prospective service users. The organisation has developed accessible licence agreements for service users. EVIDENCE: The organisation has employed a company to make a DVD guide to the home. Service users have given their permission to be filmed and have helped to think of different activities and features, which could be shown on the DVD. The filming for this was due to take place shortly after the inspection. Since the last inspection all the service users have been given new licence agreements. These are well designed with the aim of making information easier to understand. They contain photographs, pictures, symbols and plain English to help describe the terms and conditions of residency. The information includes the responsibilities of service users and the organisation and how to make a complaint. The licence agreements have been signed by all parties and an accompanying document states who has helped explain the content to service users. Mayfair Avenue DS0000017383.V261231.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 & 9 Service users’ needs are recorded within care plans. There has been significant improvement to the organisation of these. The staff need to look at ways in which a more person centred approach can be adopted. A range of risks has been assessed and recorded. Service users are supported to make choices. There has been improvements to the accessibility of some information. This work needs to continue. EVIDENCE: Since the last inspection staff have worked hard to update service user plans and records. These have improved and information is clearer. Individual needs are summarised and information from health care professionals is also included in these plans. The work of staff to update and improve this recording is commended. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 10 Some of the information within service user plans needs dating. Service user plans should be regularly reviewed and updated. Staff have worked hard to identify areas of risk and assess these since the last inspection. Risk assessments were appropriately detailed and had been signed by the service user and staff. The work of staff to complete these is commended. There has been work to make the Service User Guide and Licence agreements more accessible and this is commended. There should now be further work to make other documents, such as risk assessments and care plans, easier for service users to understand. The staff have undertaken some training in person centred planning. Further work to promote a person centred approach should take place. The Manager should make contact with local health care professionals who support staff and service users to better understand person centred planning and ways to improve communication and understanding. Service user at the home are able to make choices about the food that they eat, their environment and activities. They all have their own key to the home. The Manager said that he hoped to introduce regular service user meetings so that service users could be better informed and involved in the day-to-day running of the home. Mayfair Avenue DS0000017383.V261231.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): 11, 12, 13, 14, 15 & 17 Service users are supported to develop and maintain social, educational and practical skills. Service users are able to participate in a wide range of social and educational activities. Service users are supported to maintain relationships outside of the home. Service users are able to participate in the planning and preparation of their food. EVIDENCE: Service users participate in a wide range of educational and leisure activities. They each have a full timetable of regular activities, designed to meet their needs and wishes. Service users make good use of the local community and regularly walk to shops, cafes and the resource centre. Service users have a network of friends and families who they see regularly. The service users pursue a range of leisure activities and are members of local clubs. The Manager told the Inspector that service users were supported to take walks Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 12 and eat a healthily. Two service users had recently returned from a holiday to Euro Disney. The Manager said that all service users and their keyworkers were planning other holidays for 2006. One service user has walked out of the resource centre that they attend on a number of occasions and has indicated that at times they are unhappy with some of their planned activities. Further work to support this service user and for staff to better understand their needs and wishes should take place. The Manager should liaise with the placing authority and other professionals to make sure that this person’s needs are being met. Service users participate in some household task, such as cleaning, gardening and laundry. The service users chose the weekly menu and help to shop for and prepare the food. Menus were balanced and indicated a healthy diet. The kitchen was well stocked with fresh food. Mayfair Avenue DS0000017383.V261231.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 & 20 Personal and health care needs are recorded. The guidelines for one service user are not appropriate. Some improvements to medication procedures and recording need to be made. EVIDENCE: Personal and health care needs are recorded within individual service user files. These are monitored on a regular basis. Some of the information about assisting service users with personal care was unclear and needed better explaining. Where intervention may be intrusive, there must be clear guidelines and information about how the service users’ choice and dignity can be maintained. The guidelines for how to support one service user with a health condition had the wrong service users’ name on and must be changed. This procedure must record the individual needs of this service user and must not be generic. There is insufficient information, equipment and medication to meet the needs of this service user when on social leave. The Manager must contact the relevant health care professionals to make sure the procedure is clear and staff are appropriately equipped. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 14 The Manager said that all service users were quite healthy at the time of the inspection and that health care conditions were being monitored. There is an appropriate medication procedure and medication is stored securely. There were some gaps on administration records. A large amount of paracetamol which had been dispensed to the home earlier in the month could not be accounted for. The Manager must make sure receipt of all medication is appropriately recorded and the medication held at the home regularly audited. Medication administration records must be updated to record medication carried forward. The Pharmacist undertook a recent check on medication at the home. Following this they have offered training for staff. The Manager needs to organise this. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 15 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 There is an appropriate complaints procedure. There are appropriate procedures regarding protection of vulnerable adults and whistle blowing. Improvements need to be made to the way in which service users’ money is handled. EVIDENCE: There is an appropriate complaints procedure detailing timescales and access to the Commission for Social Care Inspection. There have been no complaints in the last twelve months. The home has adopted the London Borough of Richmond Protection of Vulnerable Adults Procedure. Richmond Homes for Life Trust also have their own procedures on abuse and whistle blowing. Service users all have their own bank accounts. Small amounts of cash are held on behalf of service users. Records of these are kept. The balances and amounts of cash are not checked daily and should be. The Manager does not undertake a regular audit of service users’ money and should do. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 16 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 environment is well maintained, homely, comfortable and clean. Service users have personalised the home and it reflects their tastes and interests. EVIDENCE: The building is a pleasant semi detached house in a residential road. The home was attractively decorated and furnished throughout and had been personalised with personal belongings, pictures and plants. There is a good size garden to the rear. Areas of the building had recently been decorated including one bedroom. Service users chose their own colour schemes, décor and furnishings. The Manager said that a recent Gas safety inspection had identified a need for a new boiler. The Manager reported that he is currently looking at this. All bedrooms are for single occupancy and have been personalised by service users. Service users showed the Inspector their bedrooms. There is a large lounge and separate dining room, which have been made homely and comfortable. The kitchen is large and there is a dining areas within this. There is a shower room and a bathroom and separate WCs. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 17 The home is suitably equipped to meet the needs of service users, including the provision of grab rails in the bathrooms and garden. The home was clean and hygienic throughout on the day of the inspection. Service users are involved in household tasks. There are appropriate procedures for infection control and laundering of clothes. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 18 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 There are appropriate procedures for the recruitment of staff. recruitment records need to be completed. Although There has been a lack of formal supervision and team meetings, however the new Manager plans to offer regular supervision and support. Training records need to be updated and there needs to be an audit of staff training needs. EVIDENCE: The home was fully staffed at the time of the inspection. The Manager said that he had met with all staff but wanted to spend some more time with each staff member on shift to get to know them better. There is a wide range of information for staff, including new and temporary staff, but there is potential to build on this resource. The Manager should look at ways to do this. The senior support worker is qualified to NVQ Level 3 and two members of staff were due to start their NVQ Level 2 shortly after the inspection. The Manager said that he is reviewing the allocation of staff, with a view to increasing staffing in the evening so that service users have more opportunities to go out and pursue individual activities. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 19 The Manager said that he wanted to introduce regular individual supervision and team meetings. A team meeting was scheduled for the day after the inspection and he said that he planned to arrange individual supervision meetings within the month. There is an appropriate procedure for recruitment and selection of staff. At the last inspection it was identified that some staff files were not complete. Work to update these has taken place and three staff files were examined. They contained most of the required information. The Manager must make sure that staff files are complete. Training records at the home are not complete and it is unclear exactly what training the staff have undertaken. The Manager said that he hopes to update this information and assess staff training needs. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 20 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, 41 & 42 The home has a new Manager who is appropriately experienced. Appropriate checks are made on health and safety. EVIDENCE: The Registered Manager left her post shortly before the inspection. The new Manager has been working at the home for a month and had had a full induction and handover. He previously worked as the Deputy Manager in the organisation’s other registered home and therefore knows the organisation and certain systems well. He already knew the service users and some of the staff from his previous role. He is qualified to NVQ Level 3 and was due to start his NVQ Level 4 in April 2006. The new Manager must make an application to be registered with the Commission for Social Care Inspection. The Manager said that he was very happy with his new post and was starting to become more familiar with the needs of the service users and the systems Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 21 at the home. The Manager said that the organisation was very supportive and that he had a good relationship with his line manager. The Manager said that the staff team were very dedicated, knew the service users well and had been very helpful and supportive of him in his new role. The Manager has started to reorganise the office and update records and paperwork, so that information is clearer and more easily accessible. Regular checks on health and safety are made and recorded. These include fire safety, first aid, equipment, general health and safety and fire. Some of the archived records are stored in the home’s loft. The Manager must make sure this room is equipped with a smoke detector. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 22 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 X 3 X 4 X 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X X X 3 2 X Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES 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 YA18 Regulation 12 13 Requirement Timescale for action The Registered Person must 31/03/06 make sure that personal care guidelines are clear, especially where procedures are intrusive. The Registered make sure: 1. Person must 30/04/06 2. YA19 12 13 Guidelines for one service user are updated to reflect their individual need and correctly record their name. There must be a clear procedure for the administration of rectal diazepam when on social leave. There must be sufficient equipment and medication. Person must 31/03/06 2. 3. YA20 13(2) The Registered make sure: 1. Medication administration records Version 5.1 Page 24 Mayfair Avenue DS0000017383.V261231.R01.S.doc are accurately. 2. completed All medication received and carried forward is recorded and regular audits take place so that all medication can be accounted for. All staff must undertake training in medication. 3. 4. YA23 13(6) 20 The Registered Person must 31/03/06 makes sure staff check the balances of service users’ money daily and that the Manager undertakes regular recorded audits. The Registered Person must 31/05/06 make sure the boiler is safe and meets gas safety standards. The Registered Person must 31/05/06 make sure staff files are complete. (Previous timescale 31/12/05) The Registered Person must 31/05/06 develop individual staff training profiles outlining training needs and training achieved. (Previous timescales 30/06/05 & 30/11/05) 5. YA24 23(2) 6. YA34 17 19 Sch 2 & 3 7. YA35 18 19 8. YA37 9 The Manager must make an 30/04/06 application to be registered with the Commission for Social Care Inspection. Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 25 9. YA42 13(4) (6) 23(4) The Registered Person must 30/04/06 make sure the loft is equipped with a smoke detector connected to the main system. 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 YA6 Good Practice Recommendations The Manager should make sure all information within service user plans is dated and regularly reviewed. The Manager should work with other health care professionals to promote a more person centred approach and to look at improving communication and understanding. The Manager should consider ways in which further information could be made more accessible to service users. The Registered Person should liaise with one service user, and their funding authority about alternative day activities in response to their indications that they are not happy with the current arrangement. 2. YA6 3. YA7 4. YA12 Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Mayfair Avenue DS0000017383.V261231.R01.S.doc Version 5.1 Page 27 - 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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