Inspection on 23/08/05 for Milbury The Leaves

This inspection was carried out on 23rd August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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 21/02/06

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 Tuesday 23/08/05 9:00 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. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 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 Kiri Uthayakumar Care Home Seven Category(ies) of Learning Disability - Seven registration, with number of places The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28/02/05 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 room, a dining room, a lounge and one service user’s 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 G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in August 05. The inspector spoke to two residents, the registered manager, the deputy manager and one senior 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? The home complied with a number of requirements made during the previous announced inspection. The home built a walk-in shower on the ground floor, which was judged of being spacious and suitable for service users needs. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 Residents are assessed appropriately and are involved within the assessment process. EVIDENCE: The inspector viewed the care plan of the most recent admission to the home. This service user was admitted on an emergency basis in July 04. Residents care plan files provided evidence of a full and comprehensive review reaching a decision in offering a permanent placement to the resident. This review was attended by family members and outside professionals. The home has a clear admissions and referral policy in place. The manager is assessing new and prospective residents. Information gathered during the initial assessment is incorporated within the care planning processes is evident. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 home has clear and well-documented care planning processes in place; residents have been involved within these processes. A wide range of very detailed risk assessments has been made available and residents are encouraged to life an independent live. EVIDENCE: The inspector sampled one care plan during this inspection. There was clear evidence that care plans are reviewed six monthly involving resident, family, care manager and outside professionals. Care plans are available in pictorial form and goals are reviewed monthly by the key worker and resident. All residents have an allocated key worker and co-key worker. The home made good progress in implementing PCP processes, but the inspector informed the registered manager to try to make better use of videos, audio cassettes and pictures. A wide range of very detailed risk assessments has been made available for inspection. The home has general risk assessments around cleaning, cooking, washing, etc. Risk assessments have been reviewed annually or more frequently if residents’ needs are changing. In addition to this the inspector viewed individual manual handling risk assessments and risk assessments The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 10 relating to service users care. Millbury has a comprehensive risk assessment policy in place and a number of staff has attended training. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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; 15; 17 Residents are supported by staff to take part in appropriate activities and life an active live. The home supports and encourages residents in having appropriate relationships with families, friends and peers. The home provides a healthy and well balanced diet to residents. EVIDENCE: Five of the seven residents living in the home access day services in Harrow and Brent. Day services are involved in the care planning processes and are invited in attending review meetings. The home is providing day service activities for two residents. All residents have a clear activity plan in their file, which is reviewed every six months. The home displays pictures of activities on a notice board in the dinning room, this is used to communicate with residents and inform them of the planned activities. The deputy manager informed the inspector that residents are involved in domestic activities such as peeling vegetable and clearing the table. However this is limited due to the nature of disabilities. The home has their own van and driver for service users. The manager informed the inspector that the home has planned a holiday to West Glamorgan in two weeks time. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 12 The home has a visitor’s policy and visitors are welcomed to the home at any time. Families are involved with the majority of residents living at the home and it was evident that the home makes every effort involving families within the care of residents. For example families, friends, etc are invited to parties, reviews, etc. The deputy manager informed the inspector that key workers contact families regularly in writing or via telephone and give up date on progress made. The home has a sexuality policy and relationships as well as sexuality are recorded in care plans. The inspector viewed the weekly menu. It was judged that the home provides a wholesome varied and healthy diet. The home records individual meal choices and residents are involved within the menu planning process. The home displays a picture of the daily meal on the notice board in the dining room. A clear record of fridge and freezer temperature was available for inspection. There was a large bowl of fruit available on the day of this inspection. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 Residents’ health needs are met and the home can access the appropriate support network. Residents medication is administered appropriately and the home has adequate policies and procedures in place. EVIDENCE: The inspector viewed Health Needs Assessments in residents files, these where judged as appropriate. A chiropodist visits residents in regular intervals. Additionally an aromatherapist and massage therapist visits the home. All residents are registered with a local GP, who visits the home regularly and attends to residents’ health care needs. The deputy manager informed the inspector having excellent relationships with the local GP practice. Individual residents receive support from the community nurse who does home visits. The deputy manager discussed the concern regarding a resident whose needs have recently changed and new unknown behaviours where noticed by the staff team. The inspector suggested of contacting Brent Learning Disabilities Team and refer the resident to psychology and/or psychiatry. The home has a very detailed medication policy in place. The inspector viewed the homes medication file, which was judged of high standard and no gaps where noted on the MAR sheet. The home clearly records medication received The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 14 and disposed of. The inspector viewed an additional sheet for staff to sign, when checking if the correct medication has been administered, this is very good practice. The inspector found that residents allergies have not been recorded; this is required. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 The home addresses complaints appropriately and residents are listened to. EVIDENCE: The inspector viewed the homes’ complaints procedure, which was available in a pictorial format and was of a good standard. The home records received complaints clearly and it was evident that these are dealt with appropriately. The complaints policy was clearly displayed and is available in the service user guide. The inspector informed the manager that she must include the CSCI full address in the complaints policy. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 Residents live in a homely, comfortable and safe environment. The home is fully accessible for wheel chair users. The home is clean and residents live in a hygienic environment. EVIDENCE: The deputy manager and senior support worker showed the inspector around the home. The home has recently redecorated the downstairs shower to a very high standard. The home is judged as being homely and residents’ rooms are furnished and decorated to high standards. Communal areas such as hallways, lounge and dining room are very worn and carpets are stained throughout the home. The inspector informed the manager that carpets must be replaced and walls to be re painted. Previous inspections found that the office/ sleep-in room is very overcrowded, this is still an issue, but the inspector feels that the home is not able meeting this requirement due to additional space not being available. Overall the inspector was satisfied with the living arrangements in the home, but requirements were made, see schedule. The home was clean and free from offensive odours during this inspection. The homes’ laundry room meets standards and previous requirements have been complied to. The home has a washing machine, dryer and sluicing facilities. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 17 The home has a policy folder designated to policies regarding Health and Safety, Infection control, manual handling, etc. Policies are judged as being robust and are reviewed regularly. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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 A well-trained and highly skilled staff team supports residents. EVIDENCE: Five staff hold NVQ Level2 qualifications or above, the other five staff permanently employed are currently working towards achieving these qualifications. This exceeds requirements made by National Minimum Standards. In addition to this all staff have an individual training and development plan, which is reviewed annually and it was evident that staff attend a large number of mandatory and specialist training. Three staff have completed their LDAF Induction and Foundation Training. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 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) 42 Residents welfare, health and safety are maintained and protected to very high standards EVIDENCE: The inspector viewed gas certificate, electrical installation, portable appliances test, Legionella test, fire equipment test, fire records, fire risk assessment, etc which were all up to date and of high standards. The home has numerous policies relating to the health and safety of residents and staff in place, these were judged of being robust and of high standards. The inspector is fully satisfied that residents Health and Safety are protected to high standards. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 20 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 x 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 3 Standard No 11 12 13 14 15 16 17 x 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 4 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Leaves Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 21 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. Standard YA20 YA22 YA24 Regulation 13(2) Requirement Timescale for action 31/08/05 4. YA24 The home must record allergies on the MAR sheet. 22(6)(a) The CSCI address must be 15/09/05 included in the complaints policy. 23(2) Communal areas downstairs 31/08/05 must be redecorated. (Expired 31/05/05). The front door must be revarnished. (Expired 31/05/05). 30/09/05 23(2)(b)(c - The cracked flooring in the )& downstairs toilet must be 13(4)(b) repaired. - The broken fridge door handle must be replaced. - The broken sink unit in Room1 must be repaired or replaced. - The stained flooring in the upstairs bathroom must be replaced. - The cracked tiles in the upstairs bathroom must be replaced. _ The manager must give consideration of redecorating communal areas throughout the home and have all carpets replaced. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 22 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 YA19 YA24 Good Practice Recommendations The registered manager should use videos, audiocassettes and pictures within the PCP process. The registerd manager should contact Brent Learning Disabilities Team for referal. Kick boards on walls and doors should be considered after redecoration is completed. The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI The Leaves G62 G11 S17427 The Leaves V243690 230805 Stage 4.doc Version 1.40 Page 24 - 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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