This inspection was carried out on 8th December 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Mencap (Chasewood Avenue) 3 Chasewood Avenue Enfield Middlesex EN2 8PT Lead Inspector
Tony Brennan Unannounced Inspection 8th December 2005 12:00 Mencap (Chasewood Avenue) DS0000010572.V265258.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 Mencap (Chasewood Avenue) DS0000010572.V265258.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. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Mencap (Chasewood Avenue) Address 3 Chasewood Avenue Enfield Middlesex EN2 8PT 020 8342 1568 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) Paula Jean Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 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. 2nd August 2005 Date of last inspection 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) DS0000010572.V265258.R01.S.doc Version 5.0 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 four areas for improvement found at the last inspection were addressed. The inspection took place over one afternoon. The senior staff assisted the inspector as the registered manager was on training. The inspector spoke with two service users and two staff. The inspector observed practice. The inspector toured the building and examined a range of records relating to the care and management of the home. The inspector would like to thank the people who assisted him in the course of the inspection. 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) DS0000010572.V265258.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 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 the following standard(s): N/A These were not inspected on this occasion. EVIDENCE: Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 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 the following standard(s): 6 Care plans do not provide detailed information on how the needs of service users will be met. EVIDENCE: The home still needs to further develop the care plans so that they provide more detailed information on the needs of service users. Senior staff explained that they were still in the process of developing programme plans for service users. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 9 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 Service users are supported to participate in the local community and they have relationships with family and other people who are significant to them. Service users are supported to take responsibility for their own lives. EVIDENCE: The staff at the home commented that service users attend day centres. Service users confirmed this and felt that it was good. The inspector was able to confirm by talking with service users and staff that trips to local shops, the cinema and the pub were arranged. Staff explained that having enough support to assist service users was an issue due to the shortage of staff. A recruitment drive is being undertaken to address this. Service users spoken to felt that they were treated with respect. The inspector observed staff offering and respecting the choices made by service users. Service users are involved in the planning of menus. Staff spoken to understand the ways that individual service users communicate their preferences and wishes. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 10 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): N/A These were not inspected on this occasion. EVIDENCE: Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 11 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): N/A These were not inspected on this occasion. EVIDENCE: Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 12 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 The home is in need of redecoration in order to ensure that it provides a homely environment for service users to live in. EVIDENCE: The inspector toured the building and found that the paintwork in the communal areas was cracked and chipped. The carpet on the first floor landing was worn and needs replacing. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 13 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): 33 35 Staff need to be recruited to ensure that there are sufficient staff to support service users at all times. Staff do have all the skills to meet the needs of service users. EVIDENCE: The inspector spoke with staff who explained that staff still need to be recruited for the home. This causes shortages of staff when trying to plan activities. Senior staff did confirm that recruitment of staff had begun. Staff spoken to confirmed that they had training on food hygiene. Certificates were seen for this and other training that confirmed that staff are receiving the necessary training. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 14 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): 40 Service users are not able to access policies and procedures in appropriate formats. EVIDENCE: The inspector spoke with senior staff who said that policies and procedures still needed to be developed in accessible formats for service users. Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 15 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 2 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Mencap (Chasewood Avenue) Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X 2 X X X DS0000010572.V265258.R01.S.doc Version 5.0 Page 16 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 YA6 Regulation 15(1) Requirement 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 1/12/05 was not met). The registered persons must ensure that the communal areas in the home are redecorated. The registered persons must ensure that the carpet on the first floor landing is replaced. The registered persons must ensure that staff are recruited for the home. (The previous time scale of 1/12/05 was not met). The registered persons must ensure that policies and procedures are available in formats that are accessible by service users. (The previous timescale of 1/12/05 was not met). Timescale for action 01/01/06 2. 3. 4. YA24 YA24 YA33 16 16 18(1)(a) 01/01/06 01/01/06 01/01/06 5. YA40 17 01/01/06 Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 17 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 Mencap (Chasewood Avenue) DS0000010572.V265258.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Southgate Area Office 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
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