Inspection on 06/05/05 for Milbury 7 Kinch Grove

This inspection was carried out on 6th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 16/12/05

Milbury 7 Kinch Grove 07/03/05

Milbury 7 Kinch Grove 26/08/04

Similar services:

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Edenvale

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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 Care Services 7 Kinch Grove Wembley Middlesex HA9 9TF Lead Inspector Andreas Schwarz Uannounced 6 May 2005 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Milbury Care Services Address 7 Kinch Grove Wembley Middlesex HA9 9TF 020 8904 0084 020 8904 0084 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Milbury Care Services Ms Barbara Bedward CRH 4 Category(ies) of LD - 4 registration, with number of places Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered for four adults with learning disabilities. Date of last inspection 7th March 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 staffed supported living scheme at Daltry House and Geneva Court, which the Manager and Deputy have been overseeing since 1 January 2005. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place in May 2005 and lasted over three hours. The manager was not available during this inspection. The inspector was assisted by one support worker and had the opportunity to talk to one service user. The inspector viewed documents and was shown around the home by the support worker. The inspector would like to take the opportunity to thank the service user and staff for being so helpful throughout this unannounced inspection. What the service does well: What has improved since the last inspection? The homes previous inspection was in March 04 and timescales of requirements have not expired to date. However the previous inspection required word processing facilities and this visit the inspector found, that the home purchased a new computer. In addition to this the home has started to document meal choices and offer a more acceptable choice of drink for breakfast. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 6 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. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 2 The home has a robust admission procedure in place; service users are appropriately placed and cared for in the home. EVIDENCE: The home had their last admission in 1993, the inspector was not able to assess these referral documents due to them being archived. The inspector however was able to assess the homes referral and admission procedure, which was judged as being detailed and compliant with National Minimum Standards. The policy states new prospective service users will be involved in the referral process, have the choice of different trial visits ranging from half day visit to overnight stays and a three months trial visit. The homes assessment form is very detailed, however the inspector recommends using pictures in addition to written text. This would enable a wider range of prospective service users to take part in the assessment process. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 6; 9 The care plans and risk assessments have been judged as being very detailed, it is evident that service users have input in these documents and offered choices in the provision of their care. Service users, their family and outside professionals involved in their care take part in the review process. EVIDENCE: The inspector sampled two care plans during this inspection. The care plans were found to be very detailed and of high standards. Care plan documents are split into two files one of them is the working file and the other much larger one; the archive file. The working file includes a service user personal profile, long and short term goals such as home life, leisure, occupation, activities, holidays, personal care, diet, death and dying, etc. In addition to this each assessed file has a detailed health action plan in place. The home has started including care planning within the Person Centre Planning process and people providing the service users circle of support are invited and involved in the review process. Risk assessments were found to be of good standards. The home assesses individual risks, such as personal care, cooking, making tea, etc. and general risk assessments such as cooking meat, using the bath chair, etc. All risk Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 10 assessments were found to be reviewed in regular intervals and signed by the risk assessor. Risk assessments are easy to access; all risk assessment are kept in a separate folder. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 12; 13; 16; 17 Service users are offered a wide range of appropriate activities and are encouraged to take part in these. The home makes good use of community resources and service users go to local pubs, restaurants, cinemas, etc. Staff were observed treating service users with respect and encourages service users taking part in their daily live. Meals were judged as nutritious and snacks are available throughout the day. EVIDENCE: Service users living at the home attend different day services, e.g. Alvic Asian day centre, Sense, Stonebridge, etc. One service user is currently not attending the day centre, due to health reasons. Service users take part in activities such as relaxation, exercise, drawing, etc. Service users are offered group or individual sessions. None of the service users living at the home are in paid employment. The inspector was fully satisfied that service users receive stimulating, culturally appropriate day services. The staff member informed the inspector, that service users access the local community. Service users visit local pubs, restaurants, cafes, and cinemas in their spare time. The inspector was informed that the home has good Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 12 neighbourly relationships and service users are well known by members of the public. Service users are offered annual holidays; this was found to be discussed in service users reviews and forms part of the care planning process. Each service user has their own activity rota, the inspector found symbols on the kitchen notice board and was informed by staff that these are used to communicate activities to service users. During this inspection only one service user was present, the inspector observed staff treating service users with respect and dignity, i.e. knocking doors before entering the room, close bathroom when supporting in personal care, etc. The inspector was informed that service users have not been issued with a key due to their complex needs. The inspector was not able to find any records of this. The manager must risk assess and document why service users are not given a key. Service users were observed choosing when to interact with staff or by themselves. Service users have access to all the rooms in the home, however previous inspections raised the need of a ramp to access the garden. Staff informed the inspector that service users take part in clearing the table, cooking, cleaning their room and maintenance of the garden, documentation of these activities was not available to assess. The manager is required to document when service users participate in domestic activities. The home has a non-smoking policy, which is dominantly displayed on the notice board in the kitchen. One service user is deaf/blind and the home has involved Sense to assess his needs. The inspector assessed menus, which were found to be detailed and current. Meal choices are documented on a separate form. Staff informed the inspector menus are planned in advance and service users can choose from different recipes. This picture of this recipe is than displayed on the table for service users to refer to during the day. This is judged as excellent practice. Snacks and fruit are readily available during the day. The inspector observed one service user having lunch, which looked and smelled appetising and the service user confirmed that he enjoys his food. The home monitors service users weight monthly. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 19; 20 Service users’ physical and emotional health needs are well supported. Service users access heath appointments and a qualified person assess health needs. Service users are supported in drug administration and the home has safe procedures in place. EVIDENCE: Each service user’s care plan file has individual health needs assessment in place. For example the home has an individual epilepsy file in place, which helps staff to follow the appropriate procedures in case of multi seizures and how to administer rectal diazepam safely. Additionally staff have informed the inspector that they receive appropriate training. Service users are registered with a local GP and the inspector was informed that service users could receive treatment in the privacy of their room. It was evident through sampling files that service users access clinicians such as Speech and Language Therapist, Psychiatrist, dentist, chiropodist, etc. Any changes in service user’s health is well documented and followed up by the key worker or manager if necessary. The inspector viewed the homes medication policy, which is of good standard and was found compliant with Royal Pharmaceutical Guidelines. The home uses Boots Monitored Dosage System and MAR sheets were found to be signed and no gaps were found during this inspection. In the front of the medication folder, the inspector assessed individual medication guidelines. The following Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 14 issues have been addressed during inspection; liquid medication bottles must be dated after opening, allergies to be entered in MAR sheet and the bottled medication in fridge must be locked away or appropriately disposed of. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 22; 23 Service users are encouraged to voice their views and the home has a reporting system in place, though further work is needed for full compliance. Service users are protected from abuse and made safe in their home EVIDENCE: The inspector viewed the home’s complaint file and complaints procedure. There were no complaints recorded since the last inspection. The home has an incident book in place and incidences have been investigated and followed up by the manager. Previous inspections raised the need for an up to date and service users friendly complaints policy, this was found to be still outstanding. However the manager informed the inspector that she is in the process of designing a new more up to date policy. The home has a Protection of Vulnerable Adults procedure in place; the procedure is available in different languages, which is good practice. The home has other policies in place to protect service users from abuse, i.e. whistle blowing, Physical Intervention, confidentiality, dealing with service users finances, etc. Staff informed the inspector that they have received POVA training provided by Brent Social Services Department. The inspector was satisfied with the homes POVA procedure and staff’s understanding and role in this. Service user’s money is locked away in the home’s safe and the inspector was not able to assess finances due to manager and deputy not being available at this inspection. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 standard(s) 24; 30 Overall the home is judged as being suitable for the needs of the service users; however further improvements are required to comply with standards. The home is found to be clean and hygienic on the day of inspection. EVIDENCE: Kinch Grove is a two storey building in a quite cul-de-sac. There is a good size lounge and kitchen with the dinning area on the ground floor. Service user’s rooms are on the ground and first floor. The home has two WC’s and two separate bathrooms. The bathroom on the ground floor has a bath chair and an adapted toilet. There is access to a large garden from the living room. The inspector was shown around the home by staff. The home is nicely decorated and has a homely feel to it. Fire doors were found to be wedged open, this practice must stop immediately and the inspector issued an immediate requirement notice. The service user’s room located on the ground floor was used to store archive boxes; these must be removed. The wardrobe in one of the service users room was found to be broken and must be replaced. The manager informed the inspector that she was in the process of purchasing a new wardrobe. The shaver light in one of the rooms had no covering and loose wires were visible, this must be remedied immediately. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 17 The home has robust Infection control policies in place and was free from any offensive odours. There is a cleaning rota in place for staff to follow. During this inspection the home was clean and staff were observed cleaning the home. The laundry area is located on the ground floor and the washing machine has a sluice programme. The dryer was broken at the day of inspection and staff were seen to carry washed clothes to the laundrette. Staff informed the inspector that a new washing machine has been ordered. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Mibury offers numerous training courses for new and old staff and a stable and experienced staff team supports service users. EVIDENCE: Staff informed the inspector that they had received numerous training courses since starting over five years ago with the organisation. The staff member confirmed that he had received training refreshers in Health And Safety, Fire Safety, Food Hygiene and Manual Handling and that he is currently in the progress completing his NVQ2 in Care. The training development plans were available for inspection. Staff said that he had received a detailed induction, regular supervisions and appraisals. New staff is completing Learning Disabilities Framework (LDAF) induction and foundation training. Staff confirmed that they are well supported by the manager and rate the training provided as being very good. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39; 42 Service users views have been taken into consideration and the home has a detailed development plan in place. Service users health and safety was judged as being of satisfactory standards and service users live in a safe and well-maintained environment. EVIDENCE: The inspector viewed the home’s development plan and was informed by the member of staff that service users have contributed in the development of the plan. This was not evident in the plan and the inspector recommends documenting how service user’s views have been taken into consideration. However the inspector found service users questionnaires and a compliment book, which had very positive feed back from family about the care provided by the home. The development plan was last reviewed in November 2004 and redecoration of the communal areas is in this year’s budget. The home has a good Health and Safety policy in place and all required certificates were found to be up to date with the exception of portable Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 20 equipment check, which expired in August 2004 and is in need of up dating. The fire risk assessment was viewed and assessed of being of good standard. The home has regular fire drills, fire checks and fire point tests. The home has an excellent Legionella Risk Assessment in place and water levels were judged as being satisfactory. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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 3 x x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x 2 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Milbury Care Services Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 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. 3. 4. 5. 6. 7. Standard YA16 YA16 YA16 YA20 YA20 YA20 YA22 Regulation 23(2)(a) 17(3)(a) 17(3)(a) 13(2) 13(2) 13(2) 22(1) Requirement The manager must provide a ramp to access the garden The manager must record why sevice users have not been issued with their own key The manager must ensure that service users domestic activities are recorded. Liquid medication bottles must be signed after opening Allergies must be documeted in service users medication file. Medication in fridge must be locked away or disposed of. The manager is required to display an up to date version of the complaints policy. Expired 30/04/05 The manager must provide a complaints policy written in a service users friendly format. Several doors are wedged open, the manager must ensure that all fire doorsare closed. The manager must ensure that windows are fitted with window restrictors (Expired 30/04/05) The manager must remove the archive boxes from the ground floor bedroom A new wardrobe in the upstairs Timescale for action 30/06/05 30/06/05 30/06/05 31/05/05 31/05/05 31/05/05 30/06/05 8. 9. 10. 11. 12. YA22 YA24 YA24 YA24 YA24 22(2) 23(4) 23 23(2)(m) 23(2)c 30/06/05 13/05/05 31/05/05 31/05/05 31/05/05 Page 23 Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 bedroom must be purchased 13. 14. 15. YA24 YA30 YA42 23(2)c 16(2)(f) 23(2)c The faulty light above the sink in one of the rooms must be repaired The manager must ensure the home has a working clothes dryer. The home must have an valid portable equipment certificate (Expired 08/04) 10/05/05 31/05/05 30/06/05 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 YA2 YA39 Good Practice Recommendations It is recomended using pictures in the assessment document. The inspector recomends to record how service users have contributed to the devlopment plan. Milbury Care Services G62 G11 7 Kinch Grove V223498 060505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex 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. 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