Inspection on 03/11/06 for Milbury 7 Kinch Grove

This inspection was carried out on 3rd November 2006.

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 no outstanding requirements from the previous inspection report, but made 3 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 16/12/05

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 Milbury 7 Kinch Grove 7 Kinch Grove Wembley Middlesex HA9 9TF Lead Inspector Dia Balraj Unannounced Inspection 3 & 9 November 2006 10:00 th Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 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 Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 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. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Milbury 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 Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 December2005 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. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on Friday 3rd November 2006 at 12:00 noon. There was one service user present in the home and a member of staff. A new carpet was being laid in the service user’s bedroom on the ground floor as well as the ground floor communal areas. The inspector stayed until 5:30 pm and was able to meet the remaining 3 service users and speak to members of staff. A second inspection took place on the 9th November 2006 to collect evidence by meeting with management and staff and to review documentation. The inspector spoke to all service users and observed the quality of care. The manager and deputy manager and 3 staff members were interviewed. All four service users are able to express their needs by using a combination of makaton and gestures and two have a certain degree of communication. What the service does well: What has improved since the last inspection? What they could do better: The following works identified by the manager and referred to the maintenance section were outstanding. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 6 Ground floor and first floor bathrooms Repair to tiling and seal around bath, fit new flooring and redecorate. Redecoration of 3 service users’ bedrooms Redecoration and fitting of new flooring to the first floor toilet. Repair to guttering 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. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 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 Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 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): 2 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. A thorough assessment of prospective residents’ needs is carried out to determine whether their needs can be met. EVIDENCE: The inspector obtained evidence from documentation, from observation and from discussion with the Deputy manager and staff. The documentation of the last admission in 1994 was examined and included a Care Management assessment plan by Parkside health authority. There was also evidence of care assessments by the Manager and a Person Centred Plan. The latter contained information on Day Care, personal care, home life, community activities, relationships with family and friends, holidays, dietary needs, health, social and emotional support, medication, leisure and menus where objects of reference are used to identify service users’ preferences. The care plans examined identified residents’ needs and the required action to achieve objectives. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 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): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users’ needs are identified and they are enabled to make choices. They are encouraged to develop independence. EVIDENCE: The inspector interviewed staff, observed the interaction between staff and service users and viewed documentation of care plans. One care file was sampled. The care plan identified the service user’s individual needs and the action taken by staff to meet his needs. There were working care files in place which contained all the current working documents staff needed i.e. care plan, risk assessments, restrictions on choice, day activities and appointments. All four service users are able to express their needs by using a combination of makaton and gestures and two have a certain degree of communication. It was evident through observation and discussion with staff that service users are able to make day to day decisions about their lives, choices of activities and friendships. Staff were able to tell the inspector how they supported the residents in their daily living activities ensuring that they led an independent lifestyle but also being mindful of any risks. Clear risk assessments had been Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 10 written for each person for example the precautions to be taken when bathing due to epileptic seizures including guidelines to minimise risks. Service users’ relatives are involved in their care, have a good rapport and communicate on a regular basis with staff. Records of the personal allowance of one service user was assessed and found to be in order. The last formal reviews were done on the 7.1.06, 25.10.05 and 25.11.05. Although care plans are reviewed monthly to take into account changes in service users’ needs, it is required that the plan is reviewed with the service user involving significant professionals and family, as agreed with the service user at least every six months and updated to reflect changing needs and agreed changes are recorded and actioned. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 15, 16, 17 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are enabled to undertake activities in the home and in the local community. Their rights are respected and they are offered a healthy diet. EVIDENCE: The inspector was able to meet and speak to all four service users on both inspections. Throughout the inspection only one service user remained at the home The service-user who is not accessing day centre provision has planned activities with staff both in, and outside of the home. The Inspector noted that the service-user who remained at home had the option of waking up later 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 supported these statements. A menu was on display highlighting the meals planned for the week and was varied and nutritious. The team is multicultural and have a good Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 12 understanding of service users’ cultural backgrounds. Staff are able to provide meals that cater for service users’ cultural requirements. 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. Each service user has an individual programme listing the various activities they engage in at the day centre. The care plan sampled demonstrated a range of activities available to the service-user, and to support communication between staff and service-users, staff use a pictorial representation of the various activities. These included swimming, gymnasium, cooking, grooming, gardening. The Inspector was able to observe staff interacting with service users on their return from the day centre and how attentive and supportive they were towards service users. There was evidence of support to service users to maintain family links and a good communication between the home and the family. Relatives and friends are invited to parties and for special occasions including Easter. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users receive appropriate personal support. The health care needs of service users are met. Service users are protected by the home’s medication policy. EVIDENCE: All four service users need help to a greater or lesser degree with their personal care. A service user was observed choosing the clothes he wanted to wear. The inspector observed that the service users were appropriately attired and their physical appearance reflected appropriate care being delivered. Service users have their choice of key worker and a good rapport was observed. The individual care plans set out the preferred routines and likes and dislikes. There was a good rapport with family and relevant professionals outside the home. The team is multicultural and staff interviews confirmed that they have a good understanding of service users’ cultural backgrounds. Service users are registered with the local GP and can make appointments as and when required. They are also enabled to access health care facilities such as Psychiatrist, epilepsy nurses, chiropodist, optician, dentist. Documentation confirmed that regular medical reviews were being carried out. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 14 The home has a medication procedure. None of the service users self medicate. The MAR sheets of two residents chosen at random confirmed that the administration of medication was in order. All permanent members of staff had followed medication training. The home ensures that only trained staff have responsibility for the administration of medication.. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. The complaints’ procedure ensures that service users views are acted upon. The POVA policy contributes to service users being protected from abuse. EVIDENCE: The complaints procedure was displayed in the lobby leading to the dining room and lounge and was also available in pictorial form. The service users appeared very happy and relaxed with staff. They nodded in a positive manner when asked whether they were happy at the home and with staff The home has not received any complaints since the last inspection. The home records comments received from the family and a number of very positive comments were noted during this inspection. The home had a POVA policy and the staff interviewed had knowledge of the policy including the Public Disclosure Act 1998. Staff had followed POVA training and had knowledge of the policy for dealing with Aggressive behaviour and of crisis intervention strategies. The home had a copy of the London Borough of Brent POVA policy to ensure that appropriate procedures are followed if required. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. 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 adequate space to the four service users. On the first inspection on the 3rd November 2006 a new carpet was being laid in the service user’s bedroom on the ground floor and vinyl flooring in the ground floor communal areas. The manager had submitted a list of works on the 7th July 2006 and a number of the works had been carried out. The following works were outstanding on this inspection: Ground floor and first floor bathrooms Repair to tiling and seal around bath, fit new flooring and redecorate. Redecoration of 3 service users’ bedrooms Redecoration and fitting of new flooring to the first floor toilet. Repair to guttering Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 17 The organisation must review their maintenance procedure and investigate why there is such a slow and poor response rate for repair requests made by the home. The home has an infection control policy and a good standard of hygiene was observed. The washing machine had the specified programming ability to meet disinfection standards. The manager stated that the services and facilities comply with the Water Supply Regulations 1999. The home was clean and hygienic. Staff were observed carrying out cleaning tasks in the absence of the service users. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 18 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 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users are supported by competent and qualified staff. EVIDENCE: The evidence was based on observation of interaction between staff and service users and interview with the manager and staff. Staff showed respect for service users and addressed them politely. Staff were observed attending to service users’ needs for example by serving them drinks between meals and devoting time to speak to them. The establishment consists of a Manager, Deputy, and 7 support workers. The inspector interviewed the manager, the deputy and 4 support workers. They demonstrated knowledge of the specific needs of residents and a knowledge of their cultural and religious backgrounds. The establishment has a staff training and development programme. The home provides Learning Disabilities Award Framework Induction to staff and a wide range of specialised training.. The team in Kinch Grove is very settled with the majority of staff including the registered manager having worked at the home for a number of years. Four out of seven staff is trained to NVQ Level 2 or above. The inspector recommends that staff receive communication training and the home manager contacts Sense to receive more specific guidance in how to support residents with audio and/or visual difficulties. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 19 Two Staff personal files were sampled and contained signed contracts, photograph of staff, 2 references, application form, and receipt of Enhanced CRB check The 4 members of staff interviewed had followed POVA and challenging behaviour training and were conversant with the requirements of the Whistle blowing policy. Information on file shows that staff received in-house training on medication by senior management. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 20 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): 37,39,42 Quality in this outcome area was good. This judgement has been made using evidence available on the site visit. Service users benefit from a well run home. Service users are confident their views underpin the self-monitoring, review and development by the home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager is experienced and having worked at Kinch Grove since 1993 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 inspector that she receives regular supervision from her line manager. The manager undertakes periodic training and had more recently followed POVA, health and safety, fire Awareness, Non violent Crisis intervention, philosophy of care and management training. Monthly management visit reports were available. Staff confirmed that the manager is approachable and very caring towards residents and staff. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 21 As part of the development plan a questionnaire is sent to the family. The documentation showed a high level of satisfaction with the care. Repairs were carried out as a result of feedback from family. The fire alarm system was checked on 17.10.06 and the central heating system on the 2.10.06. An annual inspection of fire extinguishers is due to be carried out on 02/12/06. A fire risk assessment has been carried out as well as regular fire point checks and fire drills. The Manager informed the Inspector that a night fire drill had been carried out. The electrical wiring system check expires on 2.10.07 and the public liability insurance on 1.4.07. Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 22 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 23 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 14(2)a Requirement It is required that service users’ individual plans are reviewed with them involving significant professionals and family, as agreed with the service user at least every six months and updated to reflect changing needs and agreed changes are recorded and actioned. It is required that the following works are carried out: Ground floor and first floor bathrooms Repair to tiling and seal around bath, fit new flooring and redecorate. Redecoration of 3 service users’ bedrooms Redecoration and fitting of new flooring to the first floor toilet. Repair to guttering. The organisation must review their maintenance procedure and investigate why there is such a slow and poor response rate for repair requests made by the home. Timescale for action 09/01/07 2. YA24 23 09/01/07 3. YA24 23 09/01/07 Milbury 7 Kinch Grove DS0000017457.V294811.R01.S.doc Version 5.1 Page 24 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 YA35 Good Practice Recommendations The registered manager should explore the opportunity for communication training and specialised support from Sense. 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