Inspection on 25/07/07 for Mayfair Avenue

This inspection was carried out on 25th July 2007.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfair Avenue 26/08/06

Mayfair Avenue 13/02/06

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 Simon Smith Unannounced Inspection 25th July 2007 9:00 Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 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.V349196.R01.S.doc Version 5.2 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.V349196.R01.S.doc Version 5.2 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 Melvyn Wayne Roffey Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: 29 Mayfair Avenue is home to four people who have a learning disability. The home is owned and operated by Richmond Homes for Life Trust, a non-profit making organisation providing residential and community-based services in the London Borough of Richmond. The weekly fees are £948. The home is situated in a residential road in Whitton, within walking distance of community facilities and public transport networks. There is a Statement of Purpose, which provides good information about the home and includes the aims and objectives of the service. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We used evidence from several sources when making judgements about the home. These included visiting the home and meeting residents, the manager and staff. We also looked at some records, including residents’ care plans and staff files. The home met 29 of 33 National Minimum Standards assessed at this visit. Four Standards were almost met. All residents spent some time at home during the inspection. Two residents went to a resource centre and a third went to the High Street where he visited shops, the bank and a café. One resident is not able to leave the home at the moment or to use the stairs. This affects the space available to other residents, as the conservatory is normally used as the dining area. The manager said that the home was speaking to the people who pay for the resident’s care to try and solve this problem. The manager and most of the staff have worked at the home for some time. There are regular bank and agency staff to cover any vacant shifts on the rota. The home has used some extra staff recently to support one resident whose needs have changed. Staff spoke to residents with respect and supported them to make choices. Residents’ are able to choose how they spend their time and are consulted about decisions that affect them. Records in the home are well organised and up to date. Staff carry out regular checks to make sure the home is safe. There have been no complaints about the home since the last inspection. What the service does well: Provides good support for residents to lead individual lives. Promotes residents’ participation in their community. Provides a stable staff and management team who know residents’ needs well. Promotes residents’ choice and supports residents in making decisions about their lives. Provides a clean, welcoming and homely environment. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 6 Involves healthcare professionals in residents’ care where necessary. Obtains specialist equipment when residents need it. 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. The summary of this inspection report can be made available in other formats on request. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 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.V349196.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is available to residents. There are appropriate procedures for the assessment and admission of residents. Residents are issued with a written agreement that sets out the terms and conditions of their placement. EVIDENCE: Richmond Homes for Life Trust has produced a Statement of Purpose, which provides information about the home. There is also a ‘Guide for Residents’. There are appropriate procedures for the assessment and admission of residents but there have been no changes to the resident group in the last year. The home has advised one resident’s placing authority that they are unable to meet the resident’s changing needs. Negotiations were under way with the placing authority at the time of inspection to identify a suitable alternative placement. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 9 Residents’ files contained a licence agreement that sets out the terms and conditions of their placement. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home records residents’ needs and strengths and provides good guidance for staff delivering care. Residents receive good support to make choices about their lives. The home supports residents in taking manageable risks. EVIDENCE: An individual care plan is in place for each resident. Care plans examined contained good, individualised information about each resident, identifying strengths, needs and goals. All guidelines had been updated between March and June 2007. Care plans also contained evidence that residents’ health care needs are appropriately recorded and monitored. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 11 Observation and discussion with staff and residents demonstrated that the home has a commitment to supporting residents to make choices about their lives. There is also a commitment to implementing person-centred planning and an awareness of the need to balance residents’ rights and wishes with effective risk management. Risk assessments were in place where necessary and there was evidence that residents had been involved in their development where possible. All individual risk assessments had been regularly reviewed but some general risk assessments needed review. See Requirement 1. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents participate in activities appropriate to their needs and preferences. Residents are involved in their local community. Residents’ rights and responsibilities are promoted. Residents are supported to maintain relationships with their families and friends. Residents are involved in planning the home’s menu and preparing meals. EVIDENCE: Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 13 Three residents attend Whitton Community Resource Centre and have one home base day each week. Residents are encouraged to use this time to do their personal shopping and tasks such as their laundry and housework. Two residents attend a weekly social club. Residents also have opportunities to take part in leisure activities although the manager said residents would benefit from higher staffing levels at weekends, as this would enable more outings and activities during this time. Residents are involved in their local community and make use of shops, banks and cafes. Most residents have regular contact with family members and receive support from staff to maintain these relationships where necessary. Interaction between staff and residents was positive during the inspection. Residents’ wishes and needs are clearly identified in their individual plans. Staff used appropriate forms of address when speaking to residents. Residents made clear choices about how they spent their time at the home during the inspection. The menu indicated that the home provides a varied and well-balanced diet. Staff said that they aim to support residents in making informed choices about their diet and to promote healthy eating. Residents are encouraged to contribute to menu planning and to involve themselves in preparing meals. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs are met. Residents are supported to access specialist healthcare resources where necessary. Residents’ medication is appropriately stored and recorded. EVIDENCE: Care plans contained good guidance for staff delivering care. The inspection provided evidence that the home involves healthcare professionals in residents’ care where necessary, including occupational therapists, general practitioners and community nurses. There was also evidence that residents with ongoing conditions, such as epilepsy, also have access to specialist care and regular monitoring. All medical appointments are recorded. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 15 There is an appropriate system for the storage and administration of medication. The home has an arrangement with the supplying pharmacist for training and medication checks. The last pharmacy check took place in May 2007. Staff who administer medication attend training before they are authorised to do so. Two residents’ medication records were checked and contained no errors. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place for the management of complaints. Training and guidance is provided for staff in the recognition, prevention and reporting of abuse. Residents’ monies should be checked more often. EVIDENCE: The home has an appropriate Complaints procedure. There have been no complaints about the home since the last inspection. The home works within the ‘Joint Policy on Suspected Abuse of Vulnerable Adults’. Training records demonstrated that staff attended training in the Protection of Vulnerable Adults in May 2007. The home keeps records of residents’ expenditure. Two residents’ cash books and balances were checked and found to be accurate. The manager said that the staff check residents’ balances weekly. These checks should be carried out daily for the benefit of residents and staff. See Requirement 2. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is comfortable, safe and well maintained. The communal rooms of the home are welcoming and homely. Residents’ bedrooms reflect individual preferences. Residents have access to specialist equipment when they need it. The home is clean and hygienic. EVIDENCE: The home occupies a corner property and has well-maintained gardens to the side and rear. The communal rooms include a lounge, large kitchen and conservatory. The manager said that he hopes to change the kitchen so that a Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 18 table and chairs can be accommodated, as this would better meet residents’ needs. There are shower and toilet facilities on the ground floor and a bath, shower and toilet on the first floor. The home is attractively decorated and well maintained, although the door frame in the lounge needs attention. All areas of the home were clean and hygienic at the time of inspection. There are three bedrooms on the first floor and one bedroom on the ground floor, although one resident is now unable to use the stairs and was being cared for in the conservatory at the time of inspection. This affects the communal space available to the other residents, as the conservatory is normally used as the dining area. The manager said that the home was liaising regularly with the resident’s placing authority to identify a suitable alternative placement. The home has obtained specialist equipment to meet the resident’s needs, including a hospital bed, hoist and pressure relieving equipment. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from a stable staff and management team. Staff know residents’ needs well. The manager said that staff work well as a team. Appropriate training is available to staff. Some staff need to attend training in fire, health and safety and epilepsy. Team meetings and individual supervisions should take place more regularly. EVIDENCE: The home benefits from a stable staff and management team. The manager said that the home has access to regular bank and agency staff to cover Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 20 vacant shifts. The home had recently introduced extra staff to support one resident, including waking night staff. The manager said that staff work well as a team and had supported residents and one another well through a challenging time for the service. Staff interacted positively with residents during the inspection and demonstrated a good knowledge of their needs. Three staff files were checked. These provided evidence of a robust recruitment procedure and confirmed that the home carries out appropriate pre-employment checks on staff, including Criminal Records Bureau disclosures. Three staff are working towards NVQ level 2. The manager said that two staff have yet to achieve this award but that they will begin a course in the near future. Staff training records indicated that some staff need to attend elements of core training, such as fire and health and safety. Some staff need to attend training in epilepsy. See Requirement 3. The manager has arranged moving and handling training to meet one resident’s needs. Records indicated that team meetings and individual supervision sessions have not been happening as often as they should. The manager said that team meetings and individual supervisions had not taken place regularly due to pressure on the team caused by a significant change in the needs of one resident. The Registered Person must ensure that staff are supported and have opportunities to attend regular team meetings in addition to meeting residents’ needs. See Requirement 4. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 41 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an enthusiastic manager who is committed to running the home in residents’ best interests. Records are well organised and maintained. Health and safety checks were comprehensive and up-to-date. EVIDENCE: The manager has much experience of working for Richmond Homes for Life Trust and knows the home and residents well. The manager is working towards the Registered Managers Award and has achieved registration with the CSCI. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 22 The manager said that he receives good support from his line manager, although this does not always include formal supervision. It is recommended that the manager have access to formal supervision at least six times a year. Discussion with the manager confirmed that there is a commitment to running the home in the best interests of residents and to promoting residents’ choice. Residents are encouraged to involve themselves in the routines of the home and are consulted about decisions in the home that affect them. The home has an appropriate fire detection system, which is checked weekly by staff using different call points. The fire alarm system and emergency lighting were serviced in July 2007. The home’s fire fighting equipment was checked in January 2007. The last fire drill took place in May 2007. Records in the home are well organised and maintained. Staff carry out a monthly health and safety check around the building. Portable appliances are tested to ensure their safety. An Electrical Installation Test was conducted in February 2004 and the water system was tested in June 2006. The service has valid Employers Liability Insurance until September 2007. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 23 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 3 4 X 5 3 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 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X 3 3 X Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA9 Regulation 13(4) Timescale for action The Registered Person must 30/09/07 ensure that all risk assessments are reviewed regularly. The Registered Person must ensure that residents’ monies are checked more often. The Registered Person must ensure that all staff attend training appropriate to their roles. The Registered Person must ensure that team meetings and individual supervisions take place more regularly. 30/09/07 Requirement 2 YA23 Schedule 4 18(c) 3 YA35 30/10/07 4 YA36 12(5) 30/09/07 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 YA14 Good Practice Recommendations The Registered Person should consider employing higher DS0000017383.V349196.R01.S.doc Version 5.2 Page 25 Mayfair Avenue staffing levels at weekends to enable more outings and activities during this time. 2 3 4 YA24 YA24 YA37 The Registered Person should consider replacing the kitchen. The Registered Person should make arrangements to repair the door frame in the lounge. The Registered Person should ensure that the manager has access to formal supervision at least six times a year. Mayfair Avenue DS0000017383.V349196.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V349196.R01.S.doc Version 5.2 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. 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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