Inspection on 11/04/07 for Milbury The Leaves

This inspection was carried out on 11th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury The Leaves 21/02/06

Milbury The Leaves 23/08/05

Milbury The Leaves 27/08/04

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 The Leaves 16 Balnacraig Avenue Neasden London NW10 1TH Lead Inspector Julie Schofield Key Unannounced Inspection 11th April 2007 08:10 Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 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 The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 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 The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Milbury The Leaves Address 16 Balnacraig Avenue Neasden London NW10 1TH 020 8450 8906 020 8450 8906 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 Kirija Uthayakumar Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: The Leaves is a purpose built detached property situated in a residential area in Neasden. The front of the property is paved and provides level access with off street parking for 4 cars. There is a garden at the rear of the property. The home is accessible by public transport. The nearest shopping centres are Neasden and Brent Cross. The home has its own transport. It is registered to accommodate up to 7 residents and to provide personal care. At the time of the inspection there were no vacancies. The ground floor accommodation consists of a kitchen, an office/sleeping in room, a dining room, a lounge and one of the service users’ bedrooms. The first floor accommodation comprises 6 single bedrooms. The home is equipped with aids and adaptations including a passenger lift, special wheelchairs and a specially adapted bath with a Jacuzzi facility. There are bathroom and toilet facilities on each floor. Details of the fees charged may be obtained, on request, from the manager. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Wednesday in April 2007. It started at 8.10 am and finished at 5.40 pm. During the inspection the Inspector met each of the residents and spoke with the manager and with members of staff on duty. Records were examined and a process of case tracking was used. The serving of a meal was observed, a site visit took place and working practices were observed. Residents were not able to give verbal feedback regarding the quality of the service and so time was spent with residents and support staff, observing their interactions. The Inspector would like to thank everyone who assisted during the inspection. What the service does well: What has improved since the last inspection? There were 3 outstanding requirements identified during the inspection in February 2006 and these have all been met. Since the inspection the front door has been re-varnished. The broken fridge door handle has been replaced. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 6 The cracked tiles in the upstairs bathroom have been replaced. The manager has introduced a glossary of terms used in respect of the administration of medication to assist members of staff. Staff told the Inspector about a book of useful information, which staff are obliged to sign when new items are included so that there is confirmation that the item has been read and will be put into practice. Items included guidance relating to team working and in relation to encouraging communication. In order that staff are able to demonstrate that they have understood training undertaken a quiz is used as follow up. Copies of this for fire safety training and understanding of all documents; policies and procedures etc that are in use in the home were available. A driver has been appointed and now works for 12 hours a week. Some of the hours are allocated to taking 3 residents to the Harrow Resource Centre. A programme of student nurses on placement in the home has been established and their hours are supernumerary. 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. The summary of this inspection report can be made available in other formats on request. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 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 The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 A comprehensive assessment of the needs of the resident, prior to admission to the home, enables the home to determine whether a service tailored to the individual needs of the resident can be provided. A programme of preadmission visits to the home enables the prospective resident to sample life in the home and to decide whether the service provided is acceptable. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A resident was admitted to the home in November 2006. Prior to their admission the funding authority provided information. This included an Assessment Summary, a Nursing Assessment, the minutes of a Care Plan Meeting and a Review Report. In addition the manager, the deputy manager and a senior support worker visited the prospective resident, in the care home that they were living in at the time the referral was made. The manager completed a Milbury Assessment Form, with the assistance of the key worker and senior staff working in the other care home. The assessment was thorough and gave a comprehensive picture of the needs of the prospective resident. Copies of all these documents were on file and there was evidence that family members had supported the resident during the pre-admission Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 9 process. The information given by the family was recorded on the Prospective Service User form. When the referral was made to the home the manager asked the family to visit the home. This visit took place before the manager and staff visited the prospective resident. There was a record of the prospective resident making a number of pre-admission visits to the home, including an overnight stay. The visits gave the resident the opportunity to view the accommodation, meet the staff team and meet the residents currently living in the home. There were opportunities to join residents for a meal and to take part in any activities in the home. One of the visits coincided with a party that was held in the home and the prospective resident, and their families members, were invited to attend. Records of the content of these visits i.e. the reaction of other residents, the views of staff on duty and how the prospective resident responded were available. An initial review meeting was held in January 2007 and a copy of the minutes of the meeting was on file. The home is to be commended for the quality of the records kept and for encouraging and enabling family members to support the prospective resident through the transition period. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Evaluating care plans on a regular basis ensures that changes in the needs of residents are identified and can be addressed and regular reviews of the placement confirm that the care home continues to be able to meet the individual needs of the resident. Residents have the opportunity to exercise choice in their daily lives. Responsible risk taking contributes towards the resident leading an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three case files were selected for case tracking. Each file contained a care plan and the manager had a copy of a blank pictorial care plan, which is shortly to be introduced. As new needs are identified these are added to the care plan. Care plans addressed personal, social and health care needs. Each separate need included the identification of a short-term goal, long-term goal Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 11 and an expected outcome. Each need is evaluated on a monthly basis and these were up to date. A record is kept on the care plan of the names of people that have helped the resident in the formulation of the plan e.g. the social worker, the relative, a friend etc. Care plans are based on the assessment of need and they are reviewed at least twice a year. Minutes of the review meetings were on file. As residents are unable to communicate verbally the manager has arranged for advocacy services to support the residents. None of the residents are able to manage their own finances and the financial records of 2 of the residents for which Milbury is the appointee were examined. Record sheets were up to date and included details of income and expenditure and the running total after transactions. The 2 residents each had a savings account and the savings books were available. The manager confirmed that a representative from head office called on an unannounced basis to audit financial records. Case files contained a general risk assessment, a people handling assessment and risk assessments tailored to the individual needs of the resident. There was evidence that these were subject to an annual review and the reviews were up to date. Risk assessments identified the hazard, the people that may be harmed, strategies in place, the likelihood of occurrence and what, if any, further action may be required. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Residents attending day care services are provided with an opportunity to develop their social skills. Taking part in activities and therapies and using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected. Residents are offered a varied and wholesome diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 7 residents accommodated in the care home five residents attend a day centre. Three residents attend Harrow Resource Centre on 3 days per week. One resident attends Neasden Resource Centre on 4 days per week and another resident attends Neasden Resource Centre on 5 days per week. The Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 13 sixth resident is not in good health at the moment and the seventh resident has chosen not to attend a day centre. (This resident is of retirement age). The home has the use of a mini bus and a driver. Residents make use of resources and facilities in the community including shops, shopping centres, the library, pubs etc. Some residents like to go out for a walk. Rotas are arranged so that staff are available to escort residents. Some residents attend the Apple disco, which is held on a monthly basis. There were photographs of residents taking part in outings e.g. to London Zoo, parties and barbeques. During the week massage, aromatherapy and physiotherapy sessions take place in the home on a regular basis with a qualified therapist leading the sessions. Staff give pampering sessions, story telling and music sessions during the day and on the day of the inspection residents were enjoying listening to a member of staff that was playing the keyboard. Residents went to Wales in 2006 for a holiday. A visitors’ notice was on display in the entrance hall. It reminded visitors that they were welcome at any time and that they would be asked to sign the visitors’ book when then arrived at the home and when they left. No notice was required when making a visit but a resident may not be ready to receive a visitor when the visitor arrived. Visitors were also reminded that the resident may choose not to meet with the visitor and that the wishes of the resident would be respected. Most of the residents receive visits from members of their families and family members and friends of the resident are invited to social events e.g. birthday parties. Although staff knock on the resident’s bedroom door before entering none of the residents are able to call out and to invite the member of staff to enter. Staff have to read the body language of the resident and the facial expressions to gauge whether their visit is welcome. None of the residents have a key to their room. It was noted that there was good interaction between residents and members of staff on duty. Residents can choose whether they wish to take part in an activity and members of staff gave examples of how individual residents did this. Residents’ wishes are respected. The inspection commenced at 8.10 am and the board in the dining room gave details of the menu for that day. It was in a pictorial format. During the inspection an evening meal was prepared and served. It consisted of chicken curry, potatoes and mixed vegetables. It looked and smelt appetising. The dessert was jelly. All staff have undertaken food hygiene training. The dining room is sufficient in size for residents to eat in comfort. Several residents need assistance with feeding and have a soft diet. Case files contained a nutritional assessment and the dietician has been contacted if there are concerns that a resident is under or over weight. The menu for week commencing the 9th April was on display and it was varied and wholesome. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 14 The manager said that there is a 4-week menu cycle and that menus are reviewed and amended on a regular basis. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Residents receive assistance with personal care in a manner, which respects their privacy. Residents’ health care needs are met through access to health care services in the community. The general well being of residents is promoted by assistance or support from staff in taking medication, as prescribed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Case files contained guidelines for staff in respect of how the resident preferred to be supported e.g. activities of daily living plans, continence management and bathing guidelines. Assistance with personal care was given in private and preserved the dignity of the resident. It was noted that residents were clean and tidy and smartly dressed. Choice of clothing is offered where possible, although as residents are unable to communicate verbally members of staff interpret the wishes of the resident. Technical aids and equipment are provided to assist with transfers and with personal care. There was evidence Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 16 that when necessary, specialist support and advice is sought e.g. from the dietician, the physiotherapist etc. The home has a system of key working and the details of this were on display. It was observed that when one of the student nurses assisted a resident with feeding that it was at a measured pace, there was good eye contact, there was awareness of the hazard of choking and the student nurse spoke to the resident throughout. Each case file examined contained a health action plan. The plans are reviewed on a monthly basis. Case files confirmed that residents had access to health care services i.e. regular appointments with the optician, dentist and chiropodist. There was information on file in respect of a particular health need e.g. supporting a resident that had been diagnosed with Parkinson’s. Staff supported residents on their hospital appointments and attendance at clinics. Appointments with the GP were recorded and it was noted that residents had an annual medication review. Residents had the opportunity to have a flu jab in 2006, if they wished. The storage of medication was safe, secure and orderly. The monitored dosage system is in use and the blister packs were examined. These had been appropriately opened prior to the inspection, according to the time of day and the day of the week that they were examined. Records were checked and they were up to date and complete. Each record sheet contained a photograph of the resident. Staff confirmed that they had received medication training and when asked, a member of staff was able to describe the content of the training. A medication policy is in place in the home and the medication record file also contained a copy of a risk assessment for the administration of oral medication. There were comprehensive guidelines in respect of the medication prescribed and its side effects. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 A complaints procedure is in place to protect the rights of the residents. An adult protection procedure and training in protection of vulnerable adults procedures help to promote and protect the welfare and safety of residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were copies of the complaints procedure on display in the entrance hall, next to the visitors’ book, and on the notice board outside the office. Two of the copies were in a format that was user friendly and included illustrations. The third copy is clear in its content and includes timescales for the different stages of the procedure and contact details for both the CSCI and Milbury head office. As residents cannot verbally express their concerns the home has arranged for advocacy services for each of the residents and in the event of a complaint being made by a family member, on behalf of a resident, the advocate would provide support to the resident. No complaints have been recorded since the last inspection. An adult protection procedure is in place and there was simple, clear information regarding vulnerable adults on the notice board outside the office. The manager has been trained to train members of staff in respect of adult protection procedures and her certificate of achievement was available. Staff on duty confirmed that they had received training in adult protection Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 18 procedures and that this was updated on a regular basis. Three staff took part in discussions with the Inspector and each was able to describe their responsibilities in respect of the procedure. It was noted that protection of vulnerable adults training forms part of the induction training programme. Staff confirmed that prevention of abuse is a regular agenda item for staff meetings. They also said that they receive non-violent crisis intervention training. No incidents or allegations have been recorded since the last inspection. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Residents live in a home where the general standard of maintenance is good, although some minor matters need attention. Residents live in a home where standards of cleanliness are good. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a tour of the premises took place. It was noted that the 3 statutory requirements identified during the last key inspection, relating to the premises, had now been met. Generally the upkeep of the home was good. It was furnished and decorated to a good standard and provided a comfortable and “homely” environment for residents to relax in and enjoy. Residents each have their own single bedroom. The premises were safe, bright and airy and the level of heating was sufficient for the season. Some scuffing caused by wheelchairs means that redecoration is required in the Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 20 dining room and one of the bed frames needs re-varnishing. There are some chipped and broken tiles in the kitchen and a patch on the corner of the ceiling in the laundry room, which has been caused by water damage, that need attention. Six of the seven residents use a wheelchair. A passenger lift enables residents to access all of the facilities inside the home and there is level access at the front and at the rear of the building. Aids and adaptations are in place to meet the needs of residents. It was noted that the home was clean and tidy and free from offensive odours. Laundry facilities are situated on the ground floor and access does not involve carrying laundry through areas where food is stored, prepared or eaten. The washing machine has a sluicing cycle and there is a sluice facility in the laundry room. Hand washing facilities are also present in the laundry room. Staff have received training in relation to infection control procedures. There was evidence that this is included in Day 2 of the induction programme. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 The rota demonstrated that there were sufficient staff on duty to support the residents and to meet their needs. The home continues to support staff through the provision of NVQ training, although the home does not meet the target for staff completing this training. Recruitment practices protect the welfare and safety of residents. The training needs of members of staff are identified and met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion took place with the manager regarding NVQ training. Due to changes within the staff team, the home no longer meets the target of 50 of staff with an NVQ level 2 or 3 qualification as only 5 of the 14 members of staff have achieved this qualification. One member of staff is currently studying for a qualification and the manager said that a number of staff would enrol for NVQ training in May 2007. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 22 At the start of the inspection there were 3 members of staff on duty and 2 student nurses that were on placement in the home. The hours of the student nurses were supernumerary. The manager joined the inspection during the morning. In the afternoon the 3 members of staff handed over the care of the residents to 4 other members of staff. On each shift there was a designated shift leader. The rota was examined and it was noted that there were additional carers on duty, for the morning and for the afternoon/evening shifts, later in the week, when more residents were at home during the day. Each night there are 2 members of staff undertaking waking night duties between the hours of 9.30 pm and 7.30 am. Female residents receive assistance with personal care from female carers. Care staff undertake domestic tasks during the day, when residents attend day centre. One carer on the early shift is allocated the task of preparing the lunch and one carer on the late shift is allocated the task of preparing the evening meal. Staff confirmed that staff meetings take place on a monthly basis and that all staff are expected to attend. Six members of staff have been appointed since the last inspection and the Inspector selected 4 staff files to examine. It was noted that each staff file contained an application form, with full employment history. Two written references were present on each file. Files contained a pova first clearance and evidence of a satisfactory enhanced CRB disclosure. There was proof of identity and each file also contained a health declaration. The manager said that the human resources department at head office is monitoring recruitment practices in the homes within the company. Discussions took place with staff on duty. One member of staff confirmed that she had completed the LDAF induction and foundation training and would be undertaking NVQ level 2 training soon. She confirmed that she had undertaken training in safe working practice topics, in pova and non-violent crisis intervention, in medication and in epilepsy. Another member of staff confirmed that they had completed NVQ level 3 training. A copy of the induction handbook was seen. Staff files contained copies of training certificates and there is a system of recording when training is undertaken, when the certificate of achievement or attendance is received and when refresher training is required. Training needs are identified during annual staff appraisals and there was evidence that the programme of appraisals is up to date. Although the home is able to access the company’s annual training programme the manager said that specialist training is also provided to meet the needs of residents living at the Leaves e.g. continence training. The home is to be commended for its comprehensive training programme and for the recording system in place to ensure that refresher training takes place at the correct time. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The manager demonstrates her competence and commitment to a quality service by continuing to develop her understanding, skills and knowledge through further training. Systems are in place to gather feedback on the quality of the service provided to enable the service to develop in ways that meet the changing needs of the residents. Training in safe working practice topics enables members of staff to safeguard the health, safety and welfare of the residents and regular servicing and checking of equipment used in the home ensures that items are in working order and safe to use. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 24 The manager is a qualified nurse and has successfully completed the RMA. Previously she has completed the Advanced Management in Care qualification and holds a City and Guilds teaching certificate for adults with learning disabilities. She is also a qualified trainer in the protection of vulnerable adults. Since the last inspection she has attended a number of short training courses and workshops to update her care practice and these included Health Promotion in Learning Disabilities and People Handling and Risk Assessment – Key Trainers Certificate. Copies of the certificates relating to all the qualifications were available. In addition, the manager was runner up in the “Trained Manager of the Year Award – 2006” which had been organised by Care Choices as part of their Care Training Excellence Awards 2006. The manager is to be commended for her commitment to the development of good working practices in the home and acknowledging the role that is played by training. The manager said that she welcomed feedback from resident and/or their relatives or representatives. Copies of letters sent to the home are kept on file. These were examined and feedback on the quality of the service was positive. A copy of the annual service review for 2006 was available. Information from this informs the subsequent annual development plan. Stakeholders and relatives are invited to give their comments as part of the review. During the year quality the quality manager carries out audits of the home on a spot check basis. The LFEPA visited the home in December 2006 and the letter sent to the home acknowledged and praised the overall condition of the home, the schedule for monitoring and testing and maintenance of the fire safety systems, the fire safety awareness of staff and the efficient recording keeping. The home is to be commended for the systems in place to ensure that training in safe working practice topics and regular servicing of equipment take place at the correct time. Staff on duty confirmed that they had undertaken training in manual handling, fire safety, first aid and food hygiene. Records demonstrated that the fire alarm system is tested on a weekly basis and that fire drills are held on a monthly basis. There were valid certificates for the testing of the lift, hoists, assisted bath, the portable electrical appliances, the electrical installation, the Landlords Gas Safety Record, the fire extinguishers and the fire precautionary systems in the home. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 25 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 4 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 2 33 3 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 4 X Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 26 NO 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 Standard YA24 YA24 YA24 YA24 YA32 Regulation 23.2 23.2 16.2 23.2 18.1 Requirement That the dining room is redecorated. That the chipped or broken tiles in the kitchen are replaced. That the bed frame is revarnished. That the patch on the ceiling in the corner of the laundry room is made good and redecorated. That 50 of carers achieve an NVQ level 2 or 3 qualification in care. Timescale for action 01/08/07 01/08/07 01/08/07 01/08/07 31/12/07 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 YA20 Good Practice Recommendations That the date on which the bottle of medicine is first opened is recorded on the label. Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Milbury The Leaves DS0000017427.V334044.R01.S.doc Version 5.2 Page 28 - 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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