Inspection on 16/12/05 for Milbury 7 Kinch Grove

This inspection was carried out on 16th 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 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury 7 Kinch Grove 27/10/08

Milbury 7 Kinch Grove 03/11/06

Milbury 7 Kinch Grove 06/05/05

Milbury 7 Kinch Grove 07/03/05

Milbury 7 Kinch Grove 26/08/04

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 7 Kinch Grove 7 Kinch Grove Wembley Middlesex HA9 9TF Lead Inspector Andreas Schwarz Unannounced Inspection 16th December 2005 08:00 7 Kinch Grove DS0000017457.V270832.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 7 Kinch Grove DS0000017457.V270832.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. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 7 Kinch Grove Address 7 Kinch Grove Wembley Middlesex HA9 9TF 020 8904 0084 020 8904 0084 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) Milbury Care Services Ms Barbara Bedward Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th May 2005 Brief Description of the Service: 7 Kinch Grove is part of the Milbury organisation that provides accommodation for adults with learning difficulties. The property is a semi-detached house situated in a quiet residential cul-de-sac. It is close to Kingsbury Road for shops and public transport. There is parking on the road outside and a paved area at the front of the home for up to two cars. The property has a large garden to the rear. There are three bedrooms for service users on the first floor and one on the ground floor. There are four service users living at the property. There is a supported living scheme at Daltry House and Geneva Court, which the Manager and Deputy have been overseeing since 1 January 2005. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Lead Inspector was accompanied by Monica Saunders to shadow this inspection. This unannounced inspection took place during a morning in December 2005. The registered manager was available for this inspection. The inspectors spoke to all staff on duty and all residents during this inspection. A variety of files and care records have been assessed. The inspectors would like to express their thank you to residents’, staff and manager for being open and co-operative during this inspection. What the service does well: What has improved since the last inspection? What they could do better: 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 6 This home is overall very well managed, the registered manager however must ensure to comply with repeat requirements made in this report. The registered manager must ensure having window restrictors fitted and repair the loose leg on one of the residents beds, a serious concern letter was send to the home in regards to these issues. A number of issues regarding repair and decorations must be addressed see schedule. 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. 7 Kinch Grove DS0000017457.V270832.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 7 Kinch Grove DS0000017457.V270832.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): EVIDENCE: 7 Kinch Grove DS0000017457.V270832.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): EVIDENCE: 7 Kinch Grove DS0000017457.V270832.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): 11, 13, 14, 16 Service users are given responsibility to carry out tasks to their ability Provisions for service users to eat balanced healthy meals Service users attend activities outside of the home. EVIDENCE: Throughout the inspection only one service user remained at the home because, he had sustained an injury whilst attending the day centre. The service-user who is not accessing day centre provisions has planned activities with staff both in, and outside of the home. The Inspectors were able to evidence the service-user who remained at home had the option of waking up later for breakfast. Inspectors had observed staff offering service users a choice of cereals for breakfast. Staff said three of the four service-users carry out tasks on a regular basis within the home as a part of the promotion to their life skills. The records inspected verified this in the case file recordings. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 11 Unfortunately the access to the garden area is still minimised because a ramp is not in place, the Manager indicated that the home was expecting to have the ramp in place by spring. A menu was on display highlighting the meals planned for the week and looked both healthy and nutritious. However, there were no available choices to the menu. On observation service users are supported in carrying out budgeting tasks whilst being accompanied shopping by a member of staff, and recordings of such monies spent are logged in expenditure books. The inspectors viewed a care plan demonstrating a range of activities available to the service-user, and to support communication between staff and serviceusers, staff have access to a home-made pictures and word card system. The Inspectors were able to observe staff taking a service user out of the home to do some window-shopping, and have a meal out before returning back to the home. 7 Kinch Grove DS0000017457.V270832.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): 18; 19, 20 The home offered the Service-user support in carrying out Personal Care and dressing in a manner which was comfortable The home has suitable Policies and procedures on administering medication EVIDENCE: The inspectors were able to observe that the service users were appropriately attired and their physical appearance reflected appropriate care being delivered. Examination of Health Assessment/Health Action Plan and Daily Living Plan were on file. Records showed that Care Plans were reviewed every six months. Medication records viewed. There are individual sections with a photograph attached to the MAR sheet. On inspection of the records it was noted, on one occasion there were no recordings to verify that medication had been administered, and on another sheet verification had been recorded as administered a day in advance. The deputy manager amended the record to reflect the medication as being administered; the blister pack confirmed it had been given. It was recommended staff bring dates back in-line. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 13 Medication Policies and Procedures viewed are appropriate however; the MAR sheets do not state that the service users do not have any known allergies. Manager advised of this. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 14 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 are supported and encouraged to voice their satisfaction and dissatisfaction regarding the care and service received from the home. EVIDENCE: The homes complaints procedure is available in pictorial form. The home has not received any complaints since the last inspection. The home does record compliments received separately and a number of very positive comments were noted during this inspection. The registered manager must ensure including the Commission for Social Care Inspection address in the complaints policy. The policy is displayed on the notice board when entering the home. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 15 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 nicely decorated and residents are given to opportunity to add personal touches. Residents live in a clean, hygienic and safe home EVIDENCE: The home is appropriately furnished and offers reasonable space to the four service-users. However there are areas which require attention particularly in the bedrooms where the curtains have been pulled away from the track, floor boards in one of the bedrooms is uneven causing the floor boards to protrude through the carpet, which could cause an injury, the wall paper hanging loose in several areas. Seals between the bath/washbasin areas need replacing. The Manager informed the inspection that the house was due to undergo refurbishment around January and these areas would be rectified. The Inspectors were assured that the Service Users would be away on holiday whilst the work was in progress. An immediate Requirements Notice was issued for the bed leg to be tightened. The home has since advised that this task has been completed. The bed in the ground floor bedroom has been adapted to house a motorised bed and double mattress for the service users limited mobility and has 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 16 sufficient room to accommodate the wheelchair and Zimmer frame, which is used. The kitchen has recently been refurbished and houses a new dishwasher. During inspection it was noted that staff wash-up as they go and there is no clutter around the home. Staffs were observed carrying out cleaning tasks in the absence of the service-users. Previous inspections required having window restrictor fitted, this was still found to be outstanding and a serious concern letter has been send to the regarding this. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32; 34; 35 The home provides a sufficient number of experienced staff to support the residents. Appropriate recruitment practices and procedures protect residents from unsuitable staff. Staff is trained appropriately enabling them supporting residents to good standard. EVIDENCE: Staff felt confident in carrying out the tasks of their respective roles. The home is providing Learning Disabilities Award Framework Induction to staff and a wide range of introductory and more specialists training is offered to care staff. The team in Kinch Grove is very settled and a number of staff including the registered manager has been around for a number of years. The registered manager informed the inspectors that there is currently one vacancy, which will be advertised shortly. Four out of seven staff is trained to NVQ Level2 or above, this is compliant with National Minimum Standards. The inspector recommends for staff to receive communication training and the home manager to make contact with Sense to receive more specific support in how to support residents with audio and/or visual difficulties. Staff personal files were sampled; there were new contracts (unsigned), photograph of staff, 2 x references, application form, and receipt of Enhanced CRB check. Manager advised of CRB policy employers not to hold information 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 18 of staff pertaining to CRB check other than name, enhanced reference number, date check carried out and name of person. Manager advised to destroy full copies of CRB’s held on file, and signed copies of contracts should be placed on files. Information on file shows that staff received in-house training on medication by senior management. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 19 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; 42 The home is well managed and the manager is approachable. The home is providing a safe and secure environment for service users. EVIDENCE: The registered manager has a number of years experience; she has been working in Kinch Grove since 1993 and is very familiar with the needs of the residents. She has completed her Registered Managers Award and NVQ Level 4 in Care. The registered manager informed the inspectors that she is receiving regular supervisions and does feel supported by the organisation and line manager. The inspector can confirm to receive regulation 26 reports on a monthly basis. Staff confirmed that the manager is approachable and very caring towards residents and staff. The home has all required checks such as Portable Appliances, Gas safety, electrical installation certificates in place. An annual inspection of fire extinguishers was carried out on 02/12/05 and has been duly recorded; in addition to this a quality assurance audit check has been conducted and signed off appropriately. An up to date fire risk 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 20 assessment, regular fire point checks and fire drills have been carried out. The inspector informed the registered manager that there is a need for one annual night drill to reach full compliance. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 21 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 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Kinch Grove Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000017457.V270832.R01.S.doc Version 5.0 Page 22 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. Standard YA16 YA16 Regulation 23(2)(a) 17(3)(a) Requirement The manager must provide a ramp to access the garden (Expired 30/06/05) The manager must record why service users have not been issued with their own key (Expired 30/06/05) Allergies must be documented in service users medication file. (Expired 31/05/05) Several doors are wedged open; the manager must ensure that all fire doors are closed. (Expired 13/05/05) The manager must ensure that windows are fitted with window restrictors (Expired 30/04/05 & 31/05/05) The bed leg in the ground floor bedroom must be tightened The sealant in the bathroom must be repaired. The broken towel rail in the upstairs bathroom must be replaced. The uneven floorboard in one residents’ room must be levelled. All curtains, which came of the tracking, must be rehung. DS0000017457.V270832.R01.S.doc Timescale for action 31/03/06 31/01/06 3. 4. YA20 YA24 13(2) 23(4) 31/01/06 31/01/06 5. YA24 23 31/12/05 6. 7. 8. 9. 10. YA24 YA24 YA24 YA24 YA24 23(2)(c) 23(2)(d) 23(2)(d) 13(4)(c) 23(2)(c) 16/12/05 31/10/06 31/01/06 31/01/06 31/01/06 7 Kinch Grove Version 5.0 Page 23 11. 12. 13. 14. YA24 YA34 YA34 YA42 23(2)(c) 18(4) 17(1)(b) 23(4)(e) The loose wallpaper around the home must be redecorated. Signed copies of contracts should be placed in each staffing file The bottom copy of CRB checks must be destroyed. The registered manager must ensure conducting one night fire drill per year. 31/01/06 28/02/06 31/01/06 31/01/06 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. 2. Refer to Standard YA35 YA39 Good Practice Recommendations The registered manager should explore the opportunity for communication training and specialis3ed support from Sense. The inspector recommends recording how service users have contributed to the development plan. 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 24 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 7 Kinch Grove DS0000017457.V270832.R01.S.doc Version 5.0 Page 25 - 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. 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