Inspection on 09/06/05 for Medway House

This inspection was carried out on 9th June 2005.

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

Medway House 16/10/07

Medway House 18/10/06

Medway House 05/01/06

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 62 Medway Gardens Wembley Middlesex HA0 2RJ Lead Inspector Andreas Schwarz Unannounced 9 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Medway House Address 62 Medway Gardens Wembley Middlesex HA0 2RJ 020 8385 1438 020 8904 5250 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) First Choice Care Ltd. Mr Divya Gandhi Care Home Four Category(ies) of Mental Disorder - Four registration, with number of places Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24th March 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 have a sub-specialism in caring for Asian people.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 is a modern two-storey building and is 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-planned kitchen and lounge. A small garden is to the rear of the property Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in June and lasted over four hours. The inspector spoke to all four residents and the registered manager/responsible individual Mr Gandhi and Deputy Manager Mr Kabriya were available throughout this inspection. The inspector viewed care files and other documents made available to him on request. Mr Gandhi planned a training day for this morning, which he rescheduled for the afternoon. The inspector would like to thank residents, staff and management for being so welcoming, helpful and flexible during this inspection. What the service does well: What has improved since the last inspection? The manager addressed the majority of requirements made during the previous inspection. Environmental issues have not been resolved, but the work has been assessed by a builder to be rectified. Consultation processes with residents regarding ageing and dying have commenced. Systems have been improved to access documents in the absence of the manager. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ needs are assessed appropriately and service users are involved throughout this process. EVIDENCE: The inspector viewed the homes’ assessment policy, which is very detailed and complies with NMS. The inspector discussed the admission procedure with the manager and viewed a very detailed assessment document in one residents care plan. The manager is assessing all prospective residents and after a compatibility risk assessment has been done the report is discussed in a CPN meeting. At this meeting it will be discussed if the home can meet the needs of the individual. The minutes of this meeting go in front of a panel, at this stage it will be discussed if resident is suitable and a place is offered to the individual. After the resident had a trail visit and is happy as well as satisfied with the home, a place is offered for a three-month trial. When this trial is completed a review meeting will determine if the resident is offered a permanent placement. It was evident that the home follows these processes and residents the inspector has spoken to confirmed this. Additionally it was evident in all assessment documents that residents are involved in this process throughout. The home does not accept emergency admissions. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6; 9 Care plans are very detailed and residents are involved in the care planning process. The home has clear risk assessments in place and residents are supported to live as independent as possible. EVIDENCE: The inspector viewed residents care plans, these were judged as being very detailed and a holistic approach to residents care was evident. Residents are involved in these processes and certain restrictions within service users live are explained in detail. This was an issue addressed in a previous report, but was found not being correct during this visit. For example one resident has a history of damaging property, this was clearly explained and the home drew up a contract with the individual to pay for the damages. Work has started in reviewing care plans six monthly with input from the CPN, this must continue for all residents. The inspector viewed one resident’s budget plan and observed the manager following the correct procedure as agreed with the resident in this plan. Resident care plans had contracts available and behaviours a clearly documented and monitored. All residents have an allocated key worker. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 10 Risk assessments viewed by the inspector were judged as comprehensive and clear. Risk is assessed for the individual and the group. Unfortunately risk assessment have not been reviewed, signed or dated. The manager was informed that this is required. The home has a missing persons policy in place and staff demonstrated understanding of what to do if a resident goes missing. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 standard(s) 12; 17 Residents are supported appropriately in choosing suitable activities. The home provides residents with a cultural appropriate healthy and wholesome diet. EVIDENCE: Residents informed the inspector of being able to participate in a wide range of activities. Activities are discussed within the care planning process and group activities are discussed in residents meetings. The type of activity is depending on the need and skill of the individual. This ranges from attending structured day service, to in-house music sessions, literacy and numeracy skill training, computer classes, watching a movie, etc. Residents confirmed of being involved in domestic tasks such as hoovering, emptying the bin, clean the kitchen, etc. Residents can access the community independent once the risk has been assessed. Overall the inspector was fully satisfied that residents’ life an active and fulfilling live in Medway House. However the manager informed the inspector that more can be done and the home is currently looking into Yoga or Aromatherapy sessions for the residents. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 12 The home provides a wholesome, healthy and mostly Asian vegetarian diet. The home does not have a traditional menu plan, but menu choices are discussed with residents in the morning, service users confirmed this. All residents spoke highly of the meals received in the home. Residents informed the inspector of being involved in meal preparation and shopping for fruit and vegetable on the weekend. The manager purchases tinned and non-perishable items in regular intervals. On occasions the home is providing a take away meal, the inspector was invited to sample this on the day of inspection. Meal times are relaxed and staff join residents at meal times. Meal choices are recorded in residents’ daily reports. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 standard(s) 19; 20; 21 Residents’ health and emotional needs are monitored very well and staff support residents in accessing health appointments. The homes’ medication procedure is of good standard and staff is assisting residents appropriately. The home started consulting residents in establishing their wishes if they die or get seriously ill, but more work is required to reach full compliance. EVIDENCE: Clinical visits and appointments are documented within residents care plans. All residents have their own GP and are visited regularly by CPN and Consultant Psychiatrist. Residents informed the inspector that they could see a doctor in their room without the presence of staff if they wish to do so. Residents are encouraged attending dentists, opticians and other healthcare professionals, but are given a choice if they want to attend these appointments. The inspector was unable to view the homes’ medication policy and was informed by the manager that he will post it for assessment to the inspector. The inspector viewed medication records, which are of good standard. The medication is packed by the pharmacist and administered by staff. Staff has received appropriate training and the inspector was informed that more Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 14 training is scheduled for the end of June. The inspector informed the manager that a signatory list is not available; this is required. The home has a policy on ageing and death, which is in need for review. The home started the process of consulting service users of their wishes in regards to death and dying, but very little information was available in residents care plans. This was a requirement made during the previous inspection, but was still found to be outstanding. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 standard(s) 22 Residents have a good understanding of the homes’ complaints procedure and are listened to by staff and management. EVIDENCE: Residents informed the inspector of having received the complaints procedure and have a very good understanding how and who to complain to. All residents informed the inspector of being very happy at Medway House and not having anything to complain about. The home records complaints on forms specifically designed to do this. The home does not record compliments and the inspector suggests of having a compliments book for such occurrences. The homes’ complaints policy is judged as being satisfactory, however the home must include that the CSCI can be contacted at any stage of the complaint and the CSCI name and address must be included within the policy. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 standard(s) 24 Residents living in a comfortable and well-maintained home. EVIDENCE: Medway House is a nicely decorated home. One service users room is located on the ground floor and the remaining three are on the first floor all rooms are spacious and residents are encouraged of bringing their own possessions. There is an open plan kitchen and lounge on the ground floor, a wellmaintained garden can be accessed through the lounge and residents informed the inspector of using the garden in the summer for parties and BBQ’s. One resident informed the inspector of having been involved in the maintenance of the garden. Previous inspections noted some minor issues, the manager informed the inspector that a builder has assessed these and work will commence in due course. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff supporting residents is well trained and skilled to the work required of them. EVIDENCE: The home achieved the Investors in People Award in October 2004. On the day of inspection the manager scheduled a non-violent crisis intervention training session, but re-scheduled this for the afternoon to accommodate the inspector. The inspector wants to express that this was not necessary, but appreciates the flexibility shown by the manager. All staff has a training and development plan, which is updated regularly. Staff attended compulsory as well as specialist training. The home uses different sources and resources for the training provision. 45 of the staff team is trained to NVQ Level 2 or above and the home has a qualified nurse and qualified psychologist employed. The deputy manager informed the inspector of starting his registered manager (RMA) qualification soon. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Residents live in a safe and well-maintained home. EVIDENCE: The inspector viewed gas, portable appliance and fire system certificate. All certificate were current and up to date. The home has received a fire inspection in the week before, but is awaiting the report from the fire brigade. All documents relating to fire safety were available and in good order. The home is currently in the process of up dating their COSSH procedure. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x x x x 4 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Medway House Score x 3 2 2 Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. Standard YA6 YA9 YA20 YA20 YA21 Regulation 15(2) 17(3)(a) 13(2) 13(2) 12 Requirement All care plans must be reviewed 6 monthly in line with a formal CPA review meeting Risk assessments must be reviewed, signed and dated. The manager must send the homes medication policy to the inspector. A list of initials and signatures must be provided within the medication file. The individuals files need to capture how the home will support residents with ageing, terminal care or death. (Expired 01/07/05) The manager must include CSCI name and address in the complaints policy. The manager must include that the CSCI can be contacted at any stage of the complaint. The lock in the downstairs toilet must be repaired. (Expired 01/05/05) The holes in the veneer of the kitchen work top must be repaired.(Expired 01/06/05) Timescale for action 31/08/05 31/08/05 31/07/05 31/08/05 15/09/05 6. 7. 8. 9. YA22 YA22 YA24 YA24 22(6)(a) 22 23(2)(b) 23(2)(b) 31/08/05 31/08/05 31/07/05 31/07/05 Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The home should document compliments if they are received. Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH 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 Medway House G62 G11 S17468 Medway House V230599 090605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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