Inspection on 05/01/06 for Medway House

This inspection was carried out on 5th 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Medway House 16/10/07

Medway House 18/10/06

Medway House 09/06/05

Medway House 17/09/04

Medway House 18/02/04

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

CARE HOME ADULTS 18-65 Medway House First Choice Care Limited 62 Medway Gardens Wembley Middlesex HA0 2RJ Lead Inspector Andreas Schwarz Unannounced Inspection 5th January 2006 01:00 Medway House DS0000017468.V275166.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 Medway House DS0000017468.V275166.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. Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Medway House Address First Choice Care Limited 62 Medway Gardens Wembley Middlesex HA0 2RJ 020 8385 1438 020 8904 5250 firstchoicecare1@hotmail.com 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) First Choice Care Limited Mr Divya Gandhi Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: Medway House is a care home providing personal care and accommodation for up to four people with mental health issues. The home specializes in the support of Asian people. At the time of the inspection, the group of people living at the home is of mixed gender, and there were no vacancies. The home is owned and run by Mr Ghandi, the director of First Choice Care. The home has 24-hour staffing, including one staff sleeping-over at night. The company has one other registered home, Mosaic House, which is within walking distance from Medway House. First Choice Care is providing care to residents from the Asian community. The home is located within a residential area of Sudbury, part of the borough of Brent. It is close to local shops and both bus and rail links. Parking restrictions do not apply on the road outside the home. There is parking in front of the home. The premises are a modern two-storey building and are in keeping with other homes in the street. All bedrooms are single rooms, fully furnished, and with built-in sinks. One is downstairs. The home has two bathrooms, with a walk-in shower facility in one, and a third, separate toilet downstairs. The home has an open-plan kitchen and lounge. A small garden is to the rear of the property Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in January 2006. The registered manger and deputy manager were available throughout this inspection. The inspector spoke with three residents and one care worker during this inspection. A number of files and documents have been viewed and assessed during this inspection visit. The inspector would like to thank resident’s staff and management for being helpful and welcoming during this inspection. What the service does well: What has improved since the last inspection? What they could do better: Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 6 This is a well-managed service and only a few requirements have been made during this inspection. The registered manager must ensure to prepare and forward an annual development plan to the Commission for Social Care Inspection. The repairs mentioned in this report must be addressed. Staff files must include the required documentation and all staff must receive adult protection training. 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. Medway House DS0000017468.V275166.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 Medway House DS0000017468.V275166.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): EVIDENCE: Medway House DS0000017468.V275166.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 Residents are involved within the care planning processes and are encouraged participating in reviews. Residents are consulted in regards to their care and can make informed choices about their lives. Residents’ risks are assessed appropriately and service users involvement is evident. EVIDENCE: Previous inspection provided evidence that service users are involved within care planning processes. Previous inspections required that care plans must be reviewed every six months, which has been complied with. As mentioned earlier residents are involved within the care planning process and do attend CPA meetings. Service users do manage their own finances, though if there is a risk of overspending or inappropriate use of monies, residents will receive help from the home. The home is holding money on behalf of the resident; this however is clearly documented and is part of the residents care plan. During this inspection the inspector observed staff interacting with residents and offering choices around meals and activities. Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 10 Limitations and restrictions are clearly documented and risk assessed if necessary. Previous inspections provided evidence that the home has appropriate risk assessment procedure, there was however a need to demonstrate more service users involvement in the risk assessment process, which has been complied with. Medway House DS0000017468.V275166.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): 13; 15; 16 Residents are encouraged to access the community with staff or independent. The home supports residents having relationships, provided service users are not at risk. Residents are treated with respect and are encouraged taking part in household activities. EVIDENCE: Residents informed the inspector of attending Drop in centres on a regular basis. Activity plans provided evidence of going shopping, to dinner or lunch, etc. Residents the inspector has spoken to confirmed this. The home celebrates religious festivals such as Diwali and Christmas, residents informed the inspector of having done Christmas decorations with staff. Residents have been to their annual holiday in the Midlands and positive feedback was received during this inspection. All residents are on the electoral register. The registered manager informed the inspector that the home has no problems with neighbours. The inspector viewed a relationship policy, which is judged to be of good standard. The registered manager informed the inspector that the home does not discourage relationships, he however explained that if there is a risk to Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 12 residents, the relationships will be risk assessed and restriction may be implemented. Residents confirmed of receiving regular family visits and family members are invited to CPA meetings and care plan reviews. Service users living in Medway House are self-managing around personal care; bathrooms and bedrooms are lockable to provide privacy. Residents informed the inspector that staff usually knocks before entering their room and all feel to be treated with respect by staff and management. The inspector observed residents accessing all areas in the home. Residents informed the inspector that they help around the home and weekly activity plans confirmed this. Residents are allowed to smoke in the garden. Medway House DS0000017468.V275166.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; 20; 21 Residents living in Medway House do not require personal care support; policies are in place in the event of changing needs. Medication was assessed during the previous inspection and requirements made have been complied with. The home is in the process of addressing issues relating to ageing, illness and death. EVIDENCE: The registered manager informed the inspector that residents living in Medway House do not need input in personal care. Residents are self-managing and wash, dress and toilet themselves. The manager informed the inspector, that on occasions residents are reminded having a shower or using the appropriate toiletries. Appropriate policies are however in place, if the personal care need of residents would change. The inspector assessed the homes medication procedure during the previous inspection. Requirements made by the inspector have been complied with and the standard has been met during this inspection. Previous inspections raised the need for residents being involved and consulted regarding their wishes around ageing, illness and death. The home did not Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 14 comply with this requirement, the manager however showed a questionnaire to the inspector, which was judged as being of good standard and compliant with National Minimum Standards once fully implemented. Medway House DS0000017468.V275166.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 Residents are encouraged in making complaints if not satisfied with the care they receive. Residents are appropriately protected from abuse, neglect and self-harm. EVIDENCE: The inspector assessed complaints records during the previous inspection and records have been judged as compliant. Requirements made around the homes’ complaints policy have been addressed and complied with. The home has local Protection of Vulnerable Adults guidelines in place and the policy assessed by the inspector is following governments “ No secrets” guidelines. The manager informed the inspector that some staff has attended Protection of Vulnerable Adults training provided by Brent council and certificates have been viewed when staffing files have been sampled. The inspector however informed the registered manager that all staff must receive Protection of Vulnerable Adults training. The home has a whistle blowing and other policies such as Violence and Aggression, Restraints, Receiving of Gifts, etc. in place. Medway House DS0000017468.V275166.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; 30 Residents live in a nicely decorated and comfortable home. Residents live in a clean and hygienic home. EVIDENCE: Medway House is a detached two-storey property in Sudbury. The home has four bedrooms, which are all of very good size and nicely decorated. On the ground floor of the property is a large kitchen and lounge and a good sized well-maintained garden. The home recently replaced the worktop in the kitchen, the inspector noted that the sealant between worktop and tiles has become broken and must be replaced. The lock for the downstairs toilet has been attended to, but is still not locking satisfactory and needs therefore further attention. The washing machine is located in the kitchen; this is appropriate due to none of the residents having any continence issues. The home was clean and free of any odours during this inspection. The home has a number of policies regarding hygiene and infection control in place. Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32; 34 An experienced and skilled staff team supports residents. Robust recruitment practices and procedures are in place, but personnel files must be updated to be fully compliant with National Minimum Standards. EVIDENCE: Two of the staff employed by the home holds NVQ level 2 in Care qualifications or above. The manager and deputy manager completed their Registered Managers Award. The registered manager informed the inspector that all staff has care relating qualification or care currently doing the nursing adaptation training. One member of staff has worked in a psychiatric setting before working in Medway House. This was evident in staffing files and by talking to the registered manager and staff. The home has a robust recruitment policy in place. The inspector sampled two staff files, which did not include the required information. The inspector informed the registered manager of this and pointed out that the home is required to update all there personnel files to be compliant with National Minimum Standards. Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37; 39 The home is well managed and residents benefit of having an approachable and experienced manager. Residents are consulted regarding their care and the home, but no formal documents are available. EVIDENCE: The registered manager/provider Mr Gandhi is a qualified social worker with a diploma in management studies. The registered manager has a number of years experience working with people who have mental health problems. The registered manager is attending training and seminars that help him keeping up to date with changes in the social care sector. Service users and care staff the inspector has spoken to confirmed that the manager is supportive, approachable and listens to the problems and needs residents and staff could have. The home has done service users surveys in the past. Residents have the opportunity attending residents-meetings, the inspector noted however that the most recent residents meeting was held in September 2005, the inspector Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 19 recommended of having the residents meetings in more regular intervals. There is a suggestion book available where staff, residents and visitors can leave comments about the service. The home however has no annual service development plan, which has been discussed in detail with registered manager. The home must have an annual development plan and staff, residents, families and outside professionals must be involved and consulted in this process. Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 20 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 X 2 X 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 X 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 X 12 X 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 2 3 X 2 X X X X Medway House DS0000017468.V275166.R01.S.doc Version 5.1 Page 21 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 YA21 Regulation 12 Requirement Timescale for action 28/02/06 2. 3. YA23 YA24 4. YA24 5. YA34 6. YA39 7. YA39 The individuals’ files need to capture how the home will support residents with ageing, terminal care or death. (Expired 01/07/05 & 15/09/05) 13(6) All staff must receive adult protection training. 23(2)(b) The lock in the downstairs toilet must be repaired. (Expired 01/05/05 & 31/07/05) 23(2)(b) The registered managers must ensure that the gap between kitchen sink and tiles is sealed appropriately. 19(1)(b)(i) The registered manager must ensure that all the required recruitment checks are carried out and files contain the required documents. 24(1)(a)(3) The home must have an annual development plan involving residents, staff, families and outside professionals in the consultation process. 24(2) A copy of the annual development plan must be send to the Commission for Social Care Inspection. DS0000017468.V275166.R01.S.doc 31/03/06 28/02/06 31/01/06 31/01/06 31/03/06 31/03/06 Medway House Version 5.1 Page 22 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 YA39 Good Practice Recommendations Residents meetings should be held in more regular intervals. 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