Inspection on 26/01/06 for Mayfair Avenue (3)

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mayfair Avenue (3) 01/02/07

Mayfair Avenue (3) 09/05/05

Mayfair Avenue (3) 31/01/05

Mayfair Avenue (3) 24/06/04

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 (3) 3 Mayfair Avenue Ilford Essex IG1 3DJ Lead Inspector Jackie Date Unannounced Inspection 1:30pm 26 & 30 January 2006 th th Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Mayfair Avenue (3) Address 3 Mayfair Avenue Ilford Essex IG1 3DJ 020 8518 2839 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) Royal Mencap (Housing & Support Services) Ms Kathleen Hegarty Care Home 5 Category(ies) of Learning disability (6) registration, with number of places Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mild to moderate learning disability. Date of last inspection 9th May 2005 Brief Description of the Service: 3 Mayfair Avenue is one of four homes operated by Mencap in the London Borough of Redbridge. The home is situated in a residential street close to Ilford Town Centre. There is easy access to public transport, shops and leisure activities. The home is a large terraced house with four bedrooms, a bathroom with toilet and a shower room with toilet upstairs. Downstairs there is a large open plan through lounge, kitchen, office, staff sleep-in room, laundry area, toilet and one bedroom. The house is well furnished and decorated. The bedrooms are individually decorated and personalised according to residents likes and interests. There is also a small well-maintained garden. Five adults with learning disabilities live at the home and they all need a lot of assistance and support from the staff team. Two of the residents have little or no verbal communication and have limited ability to make decisions about their lives. The residents are encouraged to be as independent as possible and have access to day services for all or part of the week. Residents are encouraged to keep in contact with their families and are supported by the home to do this. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection lasted for about three hours and took place during the afternoon. A second visit was made the following week to talk to the manager and to see some further records. It was the second of the two inspections that each home must have during the inspection year. During the two visits all of the key standards have been checked. The manager, staff and all of the residents were spoken to. All of the communal rooms in the house were seen and care and other records were checked. The main purpose of this visit was to monitor the progress of the requirements from the previous inspection. Before the visit some of the relatives and other professionals were sent letters asking for their opinions of the service. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to ensure that the service is running properly and that it continues to develop and that the staff team receive the support and supervision that they need. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 6 Relatives and staff raised concerns about insufficient permanent staff being available to cover rotas and this needs to be addressed by the organisation. The organisation also needs to ensure that staff have access to appropriate NVQ training and support to do this. A more robust system needs to be in place to ensure that all of the necessary health and safety checks are carried out regularly. 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 (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 (3) DS0000025910.V268344.R01.S.doc Version 5.0 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): These standards were not tested on this visit. However evidence from the last inspection was that information is available to enable the staff team to meet residents’ needs. If a vacancy arose the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the five standards. At the time of the last inspection standards two, three and four were tested and assessed as met. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet these needs. Information about residents has not always been updated and therefore may not contain current information. EVIDENCE: Detailed information, “all about me”, is available about each resident. This includes information about individuals and their families, their likes and wishes and how they like to be supported. It also contains appropriate photographs. This information has been incorporated into detailed support plans. These are comprehensive and contain clear objectives. Outcomes are recorded in daily logs. Care plans have been reviewed recently as required by the previous inspection, however information has not always been updated. For example one residents “all about me” was dated April 2004, another’s January 2005. Residents’ information must be kept up to date to ensure that staff know residents current needs. The degree to which residents can be involved in the development of the plan is limited due to their learning and communication difficulties. Mencap plan to introduce Person Centred Planning (PCP) and the Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 10 deputy has had training to be a facilitator for this process. Other staff have had PCP awareness training. This should mean that the service will be in a position to implement Person Centred Planning for the residents and to develop the service provided to them. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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, and 15 The residents are encouraged to be as independent as possible, to take part in activities and to be part of the local community. Residents are supported to keep in contact with their relatives and visitors are made welcome at the home. EVIDENCE: Residents are encouraged to develop their skills and each person contributes to the tasks in the home in as far as they are able. This may be to help clear the table, wash up or put the rubbish in the bin. Photographs showed residents helping to put up Christmas decorations and to decorate the Christmas tree. Staff spoken to said that they encourage the residents to do as much as possible for themselves. All of the residents have access to day services. The amount of day services varies from two days to five days per week. All of the residents need support from the staff team when they go out. They visit local pubs, leisure facilities, Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 12 shops and cinemas. Residents enjoy going to the Gateway club. Residents are asked where they want to go and what they want to do. At the start of the inspection one resident was at home and when asked if she had been out she responded quite definitely that it was too cold to go out and she wanted to stay at home. The staff team have also started to develop plans on what each resident would like to achieve. For example “ visit my parents each week, go to a pub of my choice ”, “ go out in the community with my brother, go shopping and have lunch out”. Records are kept on what has actually been done to assist the residents to meet these wishes. Therefore residents are given opportunities for social activities and are supported when they wish to do those activities. Feedback from relatives was that they receive a warm welcome when they visit and that Mayfair provides the residents with a home from home atmosphere. There was a note in a residents file from her family thanking the manager for taking their relative to her nieces first Holy Communion. One resident’s mother was very poorly and no longer able to visit the home and staff regularly took him to visit his parents. Unfortunately she recently passed away and some of the staff and residents went with him to her funeral. Residents are encouraged and supported to keep in contact with friends and relatives. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 or 19 Residents receive personal care that meets their individual needs and preferences. Staff team support the residents to get the health care that they need. EVIDENCE: The residents require support with their personal care and details of the help that they need and how they prefer to be supported are in their individual plans. Residents are encouraged to choose what to wear. One of the residents showed the Inspector the new clothes that she bought for Christmas. During the week residents are supported to get up in time to attend their day activities but get up when they want to at weekends. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. A resident has diabetes that is controlled by diet. Records show that the staff monitor this regularly and take the necessary action if any problems arise. For example to give him something to eat or drink and then check again. His diabetes is well managed and controlled by Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 14 the staff team. None of the residents are able to self medicate and staff that have received medication training administer medication. The list and specimen signatures of those trained and authorised to administer medication has been updated as required by the previous inspection. The pharmacist has been doing training sessions with the staff team on the administration of medication and they are using the National Pharmacists Association training workbook for medicines in care homes. Medication is securely stored in a locked metal cabinet in the office and is appropriately administered by the staff team. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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): These standards were not tested on this visit. However evidence from the last inspection was that the complaints procedure is in a pictorial format to help residents understand how to complain and that staff were aware of issues of abuse and the need to protect residents from abuse. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation the standards. At the time of the last inspection both standards were tested and assessed as met. There had not been any recorded complaints since the last inspection Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 and 30 The residents live in a clean and comfortable home that is suitable for their needs. EVIDENCE: The house is in Ilford and is near to the local shops, bus routes and train station. The home is clean and well maintained. The lounge and dining area are combined and the kitchen is open plan. The building is non-smoking. None of the residents smoke. The office and staff sleeping-in room are on the ground floor. There is no separate visitors room but residents can meet visitors in the office if they wish. There is a small well-maintained garden that is used by the residents. There is a toilet on the ground floor and a shower room with toilet plus a bathroom with toilet upstairs. There is a separate utility area with laundry facilities There is also one bedroom on the ground floor, which could be used for someone with reduced mobility, but as previously stated the shower and bathing facilities are upstairs. There is no lift in the building. The house is very comfortable and homely and suitable for the current needs of the residents. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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): 32, 33, 34 and 36 Problems with finding a suitable provider have meant that an appropriately qualified staff team does not support the residents. The staffing levels are sufficient to meet residents’ current needs but there are not sufficient permanent staff available to cover the rota. Staff are properly recruited and the necessary checks carried out. This helps to protect residents and keep them safe. The manager provides adequate day-to-day support but all staff need to receive regular formal supervision. EVIDENCE: Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 18 A previous inspection required that an appropriate system must be in place to ensure that staff can complete their NVQ’s and also that a minimum of 50 of the staff team achieve at least NVQ level 2 by 2005. This requirement remains outstanding. The organisation is looking for a new provider for NVQs. This is needed to ensure that competent and qualified staff support residents Two staff are on duty at peak times. Feedback from staff was that this was sufficient to meet residents’ needs. At night there is only one member of staff sleeping in, but with access to support in the event of an emergency. During a previous visit staff said that some residents were up and about during the night and early in the morning. They also said that they were regularly up during the night to check and support the residents. This was monitored, as required, for several months and records show that residents are more settled at night and that at present the night-time staffing arrangements are sufficient. At the time of the last inspection it was highlighted that it had been difficult to cover shifts and the manager and deputy were reviewing the rota and going to discuss recruitment with the service manager. However this still seems to be a problem. The home uses three regular relief staff. Two of these have been permanent staff in the past and therefore know the residents’ well. However, on the day of the inspection a member of staff telephoned in sick and the deputy was unable to find anyone to cover the shift and was on his own with all of the residents for a few hours until the manager was able to come in early for the night time sleep in shift. Feedback from staff was that more staff need to be employed. The feedback from a relative was that regular members of staff are needed to give continuity to residents and to cover the rota. There is still on staff vacancy at the home and one member of staff on long-term sickness leave. The registered person must ensure that there are sufficient staff employed to provide the service to the residents. This may require further recruitment and a specific arrangement to cover long-term ongoing sickness absence. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. The organisation operates an appropriate recruitment procedure that protects and safeguards residents. The previous inspection required all staff must receive regular formal supervision in addition to day-to-day contact in order to provide support and guidance and to monitor work with the residents. The feedback from staff was that some of them receive regular supervision but others did not. This requirement therefore remains outstanding and must be addressed by the manager. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 and 42 Appropriate management arrangements are in place to ensure that a good quality of service is provided to residents. Although all of the necessary health and safety checks are not carried out as regularly as they should be overall there is a safe environment for the residents. EVIDENCE: The manager has a lot of experience of working with people with learning disabilities and of managing residential services. The deputy also has a lot of experience of working with people with learning disabilities. Feedback from relatives was that the manager is a good manager and that their relatives are happy because of the good quality of service provided. All of the necessary health and safety checks are in place and in the past they had been carried out regularly but as at the last inspection records show that this is still not always the case and a more robust system needs to be in place. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 20 All of the required health & safety checks must be carried out regularly to ensure that a safe environment is provided for the residents. Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 2 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mayfair Avenue (3) Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 3 DS0000025910.V268344.R01.S.doc Version 5.0 Page 22 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 2 Standard YA6 YA32 Regulation 15 18 Requirement Residents’ information must be kept up to date. Appropriate systems must be in place to ensure that staff can complete their NVQs and also that a minimum of 50 of the staff team achieve at least NVQ level 2. (Previous timescale of 31/05/05 not met). The registered person must ensure that sufficient staff employed to provide the service to the residents. All staff must receive regular formal supervision in addition to day-to-day contact in order to provide support and guidance and to monitor work with the residents. All of the required health & safety checks must be carried out regularly to ensure that a safe environment is provided for the residents. (Previous timescale of 15/06/05 not met). Timescale for action 30/04/06 30/04/06 3 YA33 18 30/04/06 4 YA36 18 30/04/06 5 YA42 13, 23 31/03/06 Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Mayfair Avenue (3) DS0000025910.V268344.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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