Inspection on 23/11/05 for Milbury 6 Milverton Road

This inspection was carried out on 23rd November 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury 6 Milverton Road 20/01/09

Milbury 6 Milverton Road 05/05/06

Milbury 6 Milverton Road 21/04/05

Milbury 6 Milverton Road 22/10/04

Milbury 6 Milverton Road 30/06/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 6 Milverton Road 6 Milverton Road London NW6 6LH Lead Inspector Andreas Schwarz Unannounced Inspection 23rd November 2005 08:30 6 Milverton Road DS0000017470.V266763.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 6 Milverton Road DS0000017470.V266763.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. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 6 Milverton Road Address 6 Milverton Road London NW6 6LH 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) 020 8459 1140 020 8459 1140 Milbury Community Services Mr Stephen Andrew McKenzie Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st April 2005 Brief Description of the Service: 6 Milverton Road is located in a quite residential street in Willesden; the home is owned by Milbury Care Services and accommodates six adults with a learning disability and physical disability. The home is closely located to Willesden High Street, Willesden library, cinema, pubs, cafes and restaurants. Willesden High Road has numerous bus rotes and Willesden Green is the closest tube station. 6 Milverton Road is a detached two-storey building. There is a large kitchen and lounge on the ground floor and access to the first floor is by a through floor passenger lift. Service users rooms are located on the ground floor and first floor. There is parking in front of the house and a large well-maintained garden at the rear. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in November 2005. The inspector was assisted by all staff on duty, spoke to two residents, observed staff and service users interaction, spoke with the registered manager and viewed files and records. The inspector would like to take the opportunity thanking everybody for their help and assistance during this visit. What the service does well: What has improved since the last inspection? What they could do better: The home is well managed; the registered manager must comply with all requirements made during this and the previous inspection. The home must support residents in finding an independent advocate; this would give service users the opportunity to take greater part in the running of the home. The home must comply with requirements made regarding the administration of medication. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 6 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. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1; 2; 5 Statement of Purpose and service users guide is compliant with National Minimum Standards; this allows prospective service users making a wellinformed choice of where to live. The home is assessing prospective residents needs appropriately and encourages new service users taking part in this process. Service users guide and care plans provide each service users with information about what care is provided, there is however still a need of providing individual contracts to service users. EVIDENCE: The inspector viewed the needs assessment document of the most recent admission to the home. New residents’ needs are assessed in detail and information gathered within the assessment process forms part of the care plan once admitted to the home. Assessments viewed by the inspector have been done by registered manager and operation manager and organisational procedures and policies have been followed. The home has a detailed assessment policy in place. The inspector viewed two service users folders and three care plans none of these documents viewed contained a signed contract. The inspector discussed this with the registered manager who informed the inspector that the service users guide is part of the contract. This however is not fully compliant with National Minimum Standards; the home is therefore required supplying all residents with an individual signed contract. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Residents are encouraged making decisions and choices about their live and the care they receive. EVIDENCE: The inspector observed interactions between staff and service users, this was judged as appropriate and sensitive to the needs of the residents. Staff informed the inspector that likes and dislikes are discussed in review meetings and recorded within care plans, this was confirmed when assessing review minutes. Residents living at Milverton Road are all non-verbal and the use of pictures and symbols as a communication tool was present throughout the home. The registered manager informed the manager that the Speech of language therapist is involved and programmes have been viewed on the notice board. None of the residents have an independent advocate and the inspector informed the manager that this must be explored. The Registerd manager is responsible for managing residents finances and records sampled by the inspector have been of good standard. The registered manager is not acting as an appointee for any of the residents living in Milverton Road. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 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 the following standard(s): 12; 15; 16 Residents attend activities appropriate to their age and culture and appear to be appropriately occupied. Residents have good relation ships with families and are supported making friends or having a sexual relationship. The home respects residents’ rights and restrictions are explained in care plans. EVIDENCE: Staff informed the inspector that none of the residents is currently in paid employment. All residents attend a day service run by Milbury Care in Willesden and timetables viewed by the inspector show a variety of activities offered. In addition to this residents can access the homes sensory room and staff informed the inspector of going to the pub, cinema, restaurants, walks, etc. One of the residents is attending the Muslim group in Willesden, which is attended by disabled and non-disabled Muslims living in the area. This has been discussed with the resident’s family and is documented in the care plan. Day service participation is logged in a day service logbook and/or the daily logbook. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 11 Staff informed the inspector, that all residents with the exception of one have regular family contact. Families do visit regularly and are invited taking part within the assessment process. Residents are well known by their neighbours and staff confirmed that neighbours stop and talk to residents when they meet them during walks and/or other activities. Residents were dressed gender appropriate during this inspection. Staff informed the inspector that male staffs do not support female residents in their personal care. The inspector viewed clear sexuality guidelines in the homes’ policy manual. The inspector observed staff addressing and supporting residents in a respectful way. Residents living at the home do not have a key; this is well documented in their care plans and has been assessed appropriately. Staff was observed knocking the door before entering a service users room. The home is fully accessible to wheel chair users and the manager explained that residents could access all areas within the home. The home has a cat, which is looked after by staff. Staff informed the inspector that residents are encouraged taking part in household activities, but participation is limited due to the level of disabilities. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 12 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): 20 Staff appropriately administers medication, there is however a need for the home to comply with requirements made in previous inspections. EVIDENCE: The inspector assessed the compliance of requirements made during previous inspections. The following issues were still found to be outstanding, allergies must be recorded on the Medication Administration sheet and the home must provide records of signatures and initials regarding staff that is trained to administer medication. The inspector discussed with the registered manager that he would refer the home to the Commission for Social Care Inspection pharmacy inspector to do a full medication audit of the home. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 13 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 Residents, family members and visitors are listened to and an appropriate complaints policy is provided. EVIDENCE: The inspector viewed complaints records and no complaint has been received by the home since the last visit by the Commission for Social Care Inspection. Previous complaints have been acted upon appropriately and investigated by the appropriate person and the complainant has been informed off the outcome. The Commission for Social Care Inspection address has been added to the complaints procedure, which is available in pictorial form and displayed throughout the home. The requirement that the Commission for Social Care Inspection can be contacted at any stage of the complaint has still found to be outstanding. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 14 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): 30 Residents live in a home, which is clean and free from any offensive odours. EVIDENCE: The homes’ laundry area is spacious and can be accessed through the lounge and hallway. Floors and walls are of good standard and can be cleaned if necessary. The home has a semi professional washing machine and dryer, both machines were of good working order. The cupboard under the sink, which contains cleaning materials, was found open during this inspection and the inspector informed the registered manager that all cleaning materials must be kept in a locked cupboard when not in use. The home was free of any offensive odours during this inspection. Overall the home was clean, but skirting boards and the bottom of the doors all around the home look very worn and must be repaired. The home has robust health and safety policies and procedures in place; in addition to this a number of health and safety leaflets were displayed on the notice board in the kitchen to raise awareness. The manager informed the inspector that the homes’ hallway would be redecorated before Christmas 2005. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 15 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; 35 A strong and competent staff team supports residents. Robust recruitement practices provide service users with an appropriately vetted staff team. Staff receives appropriate training enabling them supporting residents to high standards. EVIDENCE: The inspector observed staff interacting with residents during this unannounced visit. Staff demonstrated good and sensitive interaction with residents. The inspector found that staff was listening to what residents had to say. Three staff is currently working towards achieving their NVQ in Care qualification and the assessor visits the home from the assessment centre on a monthly basis. Staff informed the inspector that the organisation is providing a very good training programme and are very supportive in achieving their NVQ qualifications. The home does not employ any trainees or anybody under the age of 18. The home has a robust recruitment policy in place. The inspector viewed three staff files. It was evident that the manager and deputy manager have conducted interviews. All files contained the required documents such as two references, CRB check, application form with work history, etc. Permanent and temporary staff informed the inspector having received a wide range of training since working in Milverton Road. The inspector viewed 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 16 individual training and development plans and it was evident that all staff have attended compulsory training such as First Aid, Manual Handling, Food Hygiene, etc and specialist training such as epilepsy management, rectal diazepam administration, etc. Staff was very positive about the training they receive. Staff spoke about having monthly team-meetings and minutes of these have been viewed during this inspection. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 17 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 Residents living in Milverton Road benefit from a well managed home. EVIDENCE: Staff informed the inspector that the registered manager is very supportive and is listening to issues raised by individuals and the team. The manager is currently working towards achieving his Registered Manager Award and NVQ in Care Level 4. During his absence an experienced deputy manager is acting on his behalf. The manager is currently managing two homes, covering while the registered manager in Roslyn Crescent is on maternity leave; the inspector was informed of this. The inspector feels that this arrangement is acceptable, but not ideal and arranged a meeting with the Operation Manager to discuss this further. The inspector informed the registered manager to record the times and dates when he is working in the other home on Milverton’s rota. The inspector noted that the home does not have a computer and the registered manager informed the inspector that he is doing any typing on his home computer, the inspector views this as not being an ideal and recommends purchasing a computer for the home 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 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 X X 2 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 Milverton Road Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X X X DS0000017470.V266763.R01.S.doc Version 5.0 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 YA5 Regulation 5(3) Requirement The registered manager and responsible individual is required providing a contract for each service user. (Expired 14/02/05 & 31/05/05) All residents must have an independent advocate. It is required to record service users allergies on the Medication Administration Sheet. (Expired 31/05/05) The home must provide a list of signatures and initials regarding staff that is trained in the administration of medication. The complaints procedure must state that CSCI can be contacted at any stage. (Expired 15/06/05) The skirting boards and bottom of doors must be redecorated. (Expired 31/05/05) Cleaning materials must be kept locked away if not in use. The registered manager must record the hours spend in Milverton Road and Roslyn Crescent on the homes’ rota. Timescale for action 31/12/05 2. 3. YA7 YA20 12(2)(3) 13(2) 31/03/06 31/12/05 4. YA20 13(2) 31/12/05 5. YA22 22(6)(b) 31/12/05 6. 7. 8. YA30 YA30 YA37 23(2)(b) 13(4)(c) 17(2) Sch(4)(7) 31/01/06 30/11/05 15/12/05 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 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 YA37 Good Practice Recommendations The organisation should consider providing a computer for the home. 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow 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 6 Milverton Road DS0000017470.V266763.R01.S.doc Version 5.0 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!