Inspection on 21/02/06 for Milbury The Leaves

This inspection was carried out on 21st February 2006.

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 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Milbury The Leaves 11/04/07

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 The Leaves 16 Balnacraig Avenue Neasden London NW10 1TH Lead Inspector Andreas Schwarz Unannounced Inspection 21st February 2006 01:00 The Leaves DS0000017427.V282689.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 The Leaves DS0000017427.V282689.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. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 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 The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd August 2005 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 their own transport. The ground floor accommodation consists of a kitchen, an office/sleeping in room, a dining room, a lounge and one service users bedroom. 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. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during an afternoon in February 06. The inspector spoke to all residents, the registered manager, the deputy manager and one support worker during this inspection. The deputy manager Mrs Beverly Petgrave was available throughout this inspection and the inspector would like to take this opportunity thanking Mrs Petgrave for being so helpful and welcoming throughout this inspection. The inspector viewed documents and records made available to him on request. The inspector would like to thank residents, registered manager and care staff for their contribution to the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 6 As raised earlier the inspector did not make any requirements during this inspection. The home however must comply with the requirements made during the previous inspection. The majority of these requirements are maintenance issues, which have been addressed by the registered manager; but have not been actioned by the organisations maintenance department. 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 Leaves DS0000017427.V282689.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 The Leaves DS0000017427.V282689.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): EVIDENCE: The Leaves DS0000017427.V282689.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): 7 The home enables and encourages residents making their own choice. EVIDENCE: The home has referred all service users to Brent Advocacy Concern and is currently waiting for having an advocate allocated. The home has recorded service users likes and dislikes. Due to their disability residents are not able to manage their own finances and Milbury Care Services is acting as an appointee for five of the seven residents. None of the residents have a key, this is clearly recorded in the homes Service Users Guide, the manager however informed the inspector that if service users needs are changing this will be reviewed on an individual basis. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13; 16 Residents are supported and encouraged accessing the community. Service users are encouraged making daily choices, e.g. when to get up, what to eat, etc. EVIDENCE: The inspector observed residents coming back from the day centre. One resident was supported by a member of staff accessing the local library. The registered manager informed the inspector that the home has very good relationships with neighbours. Due to the level of disability residents are not registered with the electoral register. Staff informed the inspector that residents go to the local pub and evidence of this was seen in care plans. The home has their own vehicle, which is unlabeled and transport cost are shared between all residents. The inspector observed staff knocking doors prior to entering service users rooms. As raised earlier residents are not issued with a key, this however is clearly recorded. One resident was observed having received mail and was given the choice who he wants to give the letter to, to support him in dealing with his correspondence. Staff was observed addressing residents with respect and their preferred name is recorded clearly in care plans. Residents were The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 11 observed accessing all areas of the home, but due to the level of physical disabilities would need staff support for this. Residents have household responsibilities and were observed clearing their plates of the dining table; the participation however is limited due the high level of physical disabilities in the home. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18; 20 The home is providing personal care and support according to service users wishes and preferences. The home supports residents appropriately in medication administration. EVIDENCE: All care plans consist of detailed personal care guidelines outlining clearly how care must be provided to the residents. The inspector noted that during this unannounced inspection residents have been dressed appropriately The home provides ceiling hoists in bedrooms and one hoist was fitted during this inspection due to deterioration in service users mobility. The inspector viewed clear and detailed guidelines regarding the use of the hoist. Massage, music, aroma and physiotherapists visit service users regularly. During this inspection, the massage therapist visited the home and residents expressed their satisfaction. Brent Speech and Language Team is involved around swallowing issues. The home has started excellent communication guidelines for residents, which must be commended. The inspector assessed the homes medication procedure during the previous inspection and assessed compliance during this unannounced inspection. The inspector noted that all requirements made regarding Standard 20 have been complied with and the standard has now been met. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22; 23 The home supports residents, visitors and family members to voice their satisfaction and dissatisfaction. Residents are protected from abuse, neglect and self-harm. EVIDENCE: The home has updated the complaints policy and included the Commission for Social Care Inspection address as required previously. The complaints policy is available in pictorial form. The inspector viewed complaints records, which were of good standard, the home has received one complaint since the last inspection, which have been dealt with satisfactory. The home has a detailed Protection of Vulnerable Adults policy in place, the inspector viewed a signatory list of staff having read this policy; this is good practice. In addition to this the home has Brent Protection of Vulnerable Adults guidelines available for staff and service users to refer to. The manager has been trained as a Protection of Vulnerable Adults trainer and is currently in the process of designing training sessions for staff. The home has currently two newly employed staff, which has not received any Protection of Vulnerable Adults training. The registered manager informed the inspector that the staff would attend the training in the near future. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in a newly decorated comfortable home. EVIDENCE: The home has been fully redecorated since the last inspection and new carpets and lino has been laid throughout. The inspector noted however that the home still has outstanding requirements and informed the registered manager that these must be complied with. The registered manager informed the inspector that she reported all maintenance issues to the organisations maintenance department and is still waiting for a reply. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32; 34 A skilled and qualified staff team understands service users needs. Residents are protected by appropriate recruitment procedures from unsuitable staff. EVIDENCE: This is a very skilled and motivated staff team. Two staff have completed their NVQ Level 3 in Care and three staff their NVQ Level 2 in Care. The registered manager informed the inspector that currently three staff are in the process of completing similar qualification. This means that currently 8/10 staff have completed or in the process of completing their NVQ qualification. The home has student nurses on placement. The home issues General Social Care Councils Code of Conduct to all new staff; staff members the inspector has spoken to confirmed this. The home has a robust recruitment policy in place, the inspector viewed three staffing files and all appropriate checks have been viewed on these files. The home does not employ or use currently any volunteers. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 16 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 Residents live in a home, which is managed and run appropriately. Residents, families and outside professional are regularly consulted regarding the development of the service. EVIDENCE: The registered manager Mrs Kirija Uthayakumar is a registered nurse and has Registered Managers Qualifications. Staff has been extremely positive about the help and support they receive from the registered manager and deputy manager. The home has excellent policies and procedures in place and the manager demonstrated clear knowledge of National Minimum Standards and changes within the regulatory context. The manager is continuously updating her knowledge and has just recently completed a Protection of Vulnerable Adults trainers training course. The inspector judges The Leaves as an excellent managed service, with a highly motivated management and staff team. The home sends regularly monthly providers visits reports to the Commission for Social Care Inspection, the reports are of high standard and compliant with The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 17 National Minimum Standards. The inspector recommends that different people than the Operation Manager do these reports. The inspector viewed the homes annual development plan, which clearly demonstrated service users and family involvement. The home has a very good history of compliance with requirements. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 X 3 X 4 X 3 X X X X The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 23(2)(d) Requirement The front door must be revarnished. (Expired 31/05/05 & 31/08/05). The broken fridge door handle must be replaced. (Expired 30/09/05) The cracked tiles in the upstairs bathroom must be replaced. (Expired 30/09/05) Timescale for action 31/03/06 2. 3. YA24 YA24 23(2)(c) 23(2)(b) 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA24 YA39 Good Practice Recommendations The registered manager should use videos, audiocassettes and pictures within the PCP process. Kick boards on walls and doors should be considered after redecoration is completed. The inspector recommends that different staff do provider’s visits. The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Leaves DS0000017427.V282689.R01.S.doc Version 5.1 Page 21 - 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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