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Inspection on 02/08/05 for Mencap (Chasewood Avenue)

Also see our care home review for Mencap (Chasewood Avenue) for more information

This inspection was carried out on 2nd August 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Those who live at the home said that they felt well cared for. The inspector observed appropriate interaction with staff. Staff had a clear understanding of the needs of people living at the home. The appropriate records were in place. People who lived at the home were supported to make choices and their level of risk was assessed. The home provided a safe and homely environment. Those who lived in the home had been supported to develop their independent living skills.

What has improved since the last inspection?

Of the seventeen areas that were identified at the last inspection fourteen had been addressed. The information on what the home provides contains all the information required. Repair had been carried out to the kitchen floor, oven door and the shower room floor. People living at the home had their needs regularly reviewed and had been consulted about how they would be supported. Risk assessments had been updated to include all the information on the potential risk to service users. All records were found to be accurate and contained all the necessary information.

What the care home could do better:

Four areas that need to be improved were identified at this inspection. There needs to be more information on how the needs of those who live at the home are met. Staff need to be recruited for the home so that the needs of people living at the home continue to be met. Training needs to be provided on food hygiene. Policies and procedures must be made accessible to those living at the home.

CARE HOME ADULTS 18-65 Mencap (Chasewood Avenue) 3 Chasewood Avenue Enfield Middlesex EN2 8PT Lead Inspector Tony Brennan Unannounced 2 August 2005 @ 09.00 am 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. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mencap (Chasewood Avenue) Address 3 Chasewood Avenue, Enfield, Middlesex EN2 8PT 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) 020 8342 1568 Ms Jan Tregelles for Royal Mencap Society Paula Wilson PC Care Home only 6 beds Category(ies) of LD Learning Disability registration, with number of places Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 specific service user who is over 65 years of age may continue to be accommodated in the home. This condition must be reviewed at such times as the specific service user vacates the home. Date of last inspection 30 November 2004 Brief Description of the Service: The home is a large detached house in a quiet road near Enfield. The home has three floors. On the ground floor there is the kitchen, lounge and laundry. There is also one large en-suite bedroom for a service user who uses a wheelchair. On the first floor there are five bedrooms and two accessible shower rooms. On the top floor there is a further bedroom, which is currently unoccupied and the staff office. The home is very comfortable and there has been a great deal of effort made to ensure the bedrooms are comfortable and reflect the tastes and preferences of the service users. There is a large, attractive garden to the rear of the house, which has seating and is used by the service users. The aims of the home are to affirm and enhance the dignity and self-respect of the service users and to pay due regard to their wishes and preferences. The service also aims to support the service users to share in and contribute to the community, and to lead an ordinary life with the assistance they require. The home is for six service users. Most of the service users attend day services in line with their individual needs. The home uses local transport to access community activities. The home has established links with local professionals so that the service users’ specialist needs can be responded to. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the sixteen areas for improvement found at the last inspection were addressed. The inspection took place over one day. The registered manager, Paula Wilson, assisted the inspector. The inspector spoke with two people currently living at the home and two staff. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: 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. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 6 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 Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 7 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) 1 2 3 The service users and prospective service users are able to access information on the service. Service users needs are assessed prior to admission to the home. The home meets the assessed needs of the service users currently living in the home. EVIDENCE: The inspector found that the service user guide was complete and contained all the information required. The service user guide had been updated to include the views of service users. The service users appeared settled in the home and the inspector found that staff responded to them in a supportive manner. The needs of service users had been assessed prior to admission and there were assessments from professionals detailing their needs. Staff spoken to understood the needs of service users. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 8 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 7 8 9 The Care Plans did not provide detailed information on how the needs of the service users would be met. The service users were consulted and informed about the restrictions placed on them. Service users are supported to make decisions within the home. Risks to the service users were assessed so that they were supported to make appropriate choices. EVIDENCE: Service users appeared well cared for and were seen to receive the support they needed. The registered manager explained that since the last inspection she had started to put more detail in the care plans on how the needs of service users should be met. The inspector found that this needed to continue so that all service users had a detailed care plan. The daily notes contained more information on the work being done with service users. Care plans were being reviewed regularly. Service users and their representatives had been consulted about the contents of the care plans. The inspector observed staff assisting a service user and saw that they involved and supported the service user to make choices about how they were supported. The inspector observed that service users were consulted about the various activities taking place in the home, for example, planning a shopping trip and planning the menu. The registered manager explained that service users would be involved informally in recruitment. Since the last inspection, detailed risk assessments had been Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 9 put in place. These detailed the risks for the service user and how they could be alleviated. The risk assessments were cross-referenced to the care plans and were discussed in the daily notes. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 10 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 Service users are offered a range of stimulating therapeutic and leisure activities. The service user is provided with a choice of varied and balanced meals. EVIDENCE: The inspector found that all service users attend day centres throughout the week. The service users spoken to confirmed that various activities were provided. The inspector observed staff supporting service users to prepare lunch and do shopping for the week. The menu, which is prepared weekly with the involvement of service users, showed that nutritionally balanced meals were offered. The inspector observed that service users were involved in the preparation of the meal. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 11 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) 18 19 20 The service users receive the support they need. The service users have access to the medical care they need. Service users are protected by safe procedures for handling medication. EVIDENCE: Service users said that staff offered support with care in ways that suited their personal preferences. The staff spoken to understood how to approach service users and what kind of support with personal care they needed. Health needs of service users were identified in their care plans and risk assessments. Records showed that service users had access to health professionals. Records of medication received, administered and returned from the home were all in order. The inspector observed medicines being given to a service user and found that this was done in a safe way. There were detailed medication profiles that detailed why the medication had been prescribed. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 12 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 23 Service users are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The complaints policy explained how to make a complaint and how it would be dealt with. The complaints record showed actions taken to resolve complaints. There were comprehensive policies on handling abuse and protection. Staff spoken to understand the signs that might indicate abuse is taking place and how to respond if they believe it is. The inspector found that training was being provided on adult protection. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 13 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 26 27 30 Service users live in a homely and safe environment. Service users bedrooms promote their independence. Toilet and bathroom facilities meet the needs of service users. The home is clean and hygienic. EVIDENCE: Since the last inspection the kitchen floor had been replaced and the oven door had been repaired. A copy of the service record for the hoist had been sent to the Commission to show that it was regularly maintained. The service users’ bedrooms where found to have the appropriate furnishings and are personalised. The home has adequate toilet and bathroom facilities to meet the needs of service users. Since the last inspection, the flooring in one of the showers had been replaced. The inspector found that the home was clean and hygienic. Staff spoken to understood how to prevent cross infection and equipment was provided for this purpose. The laundry equipment had been moved to a safer part of the home away from service users. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 14 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) 31 32 33 34 35 36 Staff have clearly defined roles that ensure the needs of service users are met. Staff do not have all the skills to meet the needs of the service users. The home does not have sufficient staff to meet the needs of the service users. The service users are protected by the home’s recruitment procedures. Staff are supervised to ensure that the needs of service users are met. EVIDENCE: The inspector found that the job descriptions outlined the tasks required to meet the needs of the service users. Staff spoken to were aware of their roles and responsibilities. Staff were observed working with the service users and were seen to be offering appropriate and sensitive support. 50 of staff have NVQ in care at level three and the rest of the staff are working towards this. The training record showed that staff had the required training with the exception of food hygiene. An appropriate induction programme is in place. The rota showed that the staff level was consistently maintained. The inspector saw that extra staff had been provided for the provision of some activities. The inspector found that there was still need to recruit more staff for the home. The inspector examined four staff files and found that they did contain all the required documentation relating to the recruitment of staff. Staff spoken to confirmed that they had regular supervision and demonstrated an appropriate Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 15 response to the needs of service users. There were records of supervision sessions and staff meetings. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 16 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) 39 40 41 42 Service users views and feedback are used as the basis for developing the home. All the necessary policies and procedures are in place, but not all of them are available in formats which are accessible to service users. Records are maintained to ensure the safety of service users. Service users and staff health and safety is promoted. EVIDENCE: The registered manager explained that a survey had been carried out of the views of service users, relatives and professionals to ensure that a quality service is provided. The inspector saw a sample of these surveys and the registered manager explained that a report outlining the findings and action to be taken is being prepared. Policies were in place to cover all the required areas. The registered manager explained that only the fire and complaints policies had been put into formats which are accessible to service users. The inspector asked that other policies that are relevant to service users (for example adult protection) are made accessible to service users. The inspector found that all the records examined were clearly written and contained the necessary information. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 17 Staff had the required safety training with the exception of food hygiene. The inspector found that a record of accidents was in place. The required certificates for gas, Legionella and electrical safety were in place. The registered manager explained that hard wiring tests had not been carried out. The home had a risk assessment for all working practices in the home. The inspector found that there had been regular fire drills, alarm testing and training taking place. Staff spoken to understood how to use fire safety equipment. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 18 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 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 3 x x 3 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 3 3 2 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Mencap (Chasewood Avenue) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 2 3 3 x G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 19 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 6 Regulation 15(1) Requirement Timescale for action 1/10/05 2. 33 18(1)(a) 3. 4. 35 40 18(1)(a) 17 The registered persons must ensure that service users care plans give detailed information on how the needs of service users would be met. (The previous timescale of 1/2/05 was not met). The registered persons must 1/12/05 ensure that staff are recruited for the home. (The previous time scale of 1/3/05 was not met). The registered persons must 1/12/05 ensure that training is provided on food hygenie. The registered persons must 1/12/05 ensure that policies and procedures are available in formats that are accessible by service users. (The previous timescale of 1/2/05 was not met). 5. 6. Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 20 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 Good Practice Recommendations Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA 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 Mencap (Chasewood Avenue) G59 S10572 Mencap Chasewood Avenue V240466 02.08.05 Stage 4.doc Version 1.40 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!