Inspection on 01/11/05 for Oxberry Avenue, 25

This inspection was carried out on 1st November 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oxberry Avenue, 25 15/05/08

Oxberry Avenue, 25 23/07/07

Oxberry Avenue, 25 08/11/06

Oxberry Avenue, 25 11/04/05

Oxberry Avenue, 25 16/11/04

Oxberry Avenue, 25 10/05/04

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 Oxberry Avenue, 25 Oxberry Avenue 25 Oxberry Avenue Fulham London SW6 5SP Lead Inspector Tony Lawrence Unannounced Inspection 1st November 2005 11:00 Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 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 Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 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. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Oxberry Avenue, 25 Address Oxberry Avenue 25 Oxberry Avenue Fulham London SW6 5SP 020 7736 2427 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) Yarrow Housing Ms Georgina Frances Morgan Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th April 2005 Brief Description of the Service: Oxberry Avenue is a registered care home providing accommodation and personal care for 5 women with a learning disability. The property is owned by the Threshold Housing Association and the care is provided by Yarrow Housing Limited, a voluntary organisation. The home opened in 1987 and is situated in a quiet residential street in Fulham, close to shops and public transport. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Tuesday 1st November 2005 from 11:00 – 13:30. The Inspector spent time talking with people living in the home, the manager and staff. He also checked care records and toured the building with the manager. Standards of care and accommodation are good and people living in the home are well supported to take part in a range of activities. Six of the seven requirements made at the last inspection have been met. What the service does well: What has improved since the last inspection? 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. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 6 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 Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 7 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): The home has clear procedures for managing the referral and admission of new service users. EVIDENCE: The key Standard was met at the last inspection in April 2005. Since the last inspection there have been no changes to the group of people living at Oxberry Avenue. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9. Standards of care planning and risk assessment are good, making sure that staff know the care needs of individuals and they receive the support they need. EVIDENCE: To assess these Standards the Inspector checked the care plans for two people living in the home. The manager explained that Yarrow uses a system of ‘person centred planning’ (PCP) based on involving service users in planning the care and support they receive. The two PCP’s checked during this visit were reviewed in August and September 2005. Staff supported both service users to complete a Planning Book and excellent use has been made of photos, pictures and symbols to make the information more accessible. The Planning Books enable service users to prepare for their PCP meeting and record their wishes and aspirations. Both plans included some clear goals, a requirement made after the last inspection. These include supporting one person to attend a local church and arranging dental and optician appointments a second person. The Inspector also checked the log books for the two service users and these showed that staff are working with individuals to meet agreed goals. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 9 The Inspector also checked the home’s risk assessments. The standard of risk assessment in the home is good but staff must make sure that risk assessments agreed as part of care plans are completed. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 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): 12, 13 and 14. People living in the home are well supported to take part in a range of appropriate activities. EVIDENCE: The key Standards were all met at the inspection in April 2005. During this visit the Inspector saw staff supporting all five people living in the home to take part in activities. One person went to the local library to choose some music CD’s; a second person went out for a walk and shopping with a member of staff; two other service users were at home in the morning listening to music in the lounge. Both people later went out with staff. When the Inspector arrived at the home, one service user was still in bed. The manager supported her with her personal care and getting her breakfast. This person also later went out for a walk with a member of staff. The Inspector also saw the log books of individual service users and these show clearly that each person is supported to regularly make use of facilities in the local community. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 11 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): 20. The systems for the administration of medication are clear, ensuring service users’ medication needs are met. EVIDENCE: The key Standards were all met at the inspection in April 2005. During this visit the Inspector checked the medication records for all five people living in the home. The home has developed clear medication guidelines for staff and records were well completed. Secure storage is provided for all prescribed medication brought into the home. The manager confirmed that the organisation’s policy on the ageing, illness and death of a service user has been finalised and implemented in the home. This was a requirement in the last inspection report. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 12 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): 23. The home has a complaints procedure that is accessible to service users and there is some evidence that staff respond to service users’ views. EVIDENCE: Both key Standards were met at the last inspection in April 2005. During this visit the Inspector checked the finance records for two people living in the home. Both records were very well maintained and receipts are obtained for any purchases made with service users’ personal money. It is a recommendation of this report that the manager or deputy manager should check and countersign the record where large sums of money are spent on behalf of service users. The home’s complaints procedure has been produced in a format that is more accessible to service users. The manager confirmed that there have been no formal complaints since the last inspection. In most cases, the record of accidents and incidents involving service users is well completed by staff. There is a need to ensure that all accident and incident reports are completed fully and copies of reports written following significant incidents must be sent to the Commission for information. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 13 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, 25, 27, 28 and 30. The home provides a good standard of comfortable accommodation for service users. EVIDENCE: Both key Standards were met at the last inspection in April 2005. During this visit the Inspector saw all communal areas of the home and four service users’ bedrooms. All parts of the home are clean and tidy, good quality furniture is provided and the home is well decorated. The last inspection report noted that the shower room is located on the top floor and the water pressure is not good enough to provide a satisfactory shower. The report included a requirement that Yarrow must ensure people living in the home can use the home’s shower. The manager confirmed that the Housing Association’s surveyor has visited and recommended a pump is fitted to the boiler to improve water supply to the shower. This recommendation has been passed to the Housing Association but the work has not yet been completed. The requirement made after the last inspection is repeated in this report and Yarrow and the Housing Association Yarrow must ensure that service users have use of a working shower without further delay. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 14 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 and 33. The home is well staffed to support service users. There is still a need to make sure that permanent staff are recruited to ensure consistent standards of care are provided. EVIDENCE: When the Inspector arrived at the home, the manager was alone on duty. She confirmed that two service users had gone out earlier, each supported by one member of staff. The home currently has vacancies for two residential support workers and one day services worker. The manager told the Inspector that these posts should be advertised shortly. Permanent bank staff cover the two residential worker posts and the manager is arranging for other staff to cover the day service worker’s post. The Inspector checked the home’s diary and this was evidence that all staff receive regular formal supervision from the home’s manager. The manager also confirmed that all staff have a completed Criminal Records Bureau check and a record is kept in the home of these. The Inspector noted that one member of staff who was due to start a shift at 12:00 had not arrived at the home by 13:30. The manager was able to contact the staff member who explained that she was late due to personal reasons. While the Inspector understands that this is sometimes unavoidable, Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 15 staff must always make sure they ring the home if they cannot start a shift on time. The manager told the Inspector that two permanent staff and one bank staff have completed their NVQ Level 2 qualification training. The deputy manager has completed her NVQ Levels 2 and 3 and two more staff are due to start their NVQ Level 2 training this month. While the home will not meet the target of 50 qualified staff by 31/12/05, the Inspector was satisfied that arrangements are in place to enable staff to complete the required training during 2006. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 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, 41, 42 and 43. The manager is well supported by a staff team who have a clear understanding of their roles. EVIDENCE: Two key Standards not met at the last inspection have now been met. Policies and procedures have been reviewed and implemented and yarrow has begun work to introduce a quality assurance system that includes the views of service users. The Inspector felt that the manager has a good understanding of the needs of each person living in the home and the support they need. Staff in the home work well together to make sure that service users can take part in a wide range of activities and the home is well staffed to enable this to happen. The manager told the Inspector that she had started her NVQ Level 4 qualification training but there is a need to ensure that this is completed. The Inspector checked a number of records kept in the home, including care plans, finance and medication records, log books and the staff rota. Standards Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 17 of record keeping in the home are good and all records are well maintained and up to date. No health and safety issues were noted during this visit. Yarrow must ensure that senior managers from within the organisation carry out monthly monitoring visits. During this visit the Inspector noted that there was no record of monitoring visits being made in September or October 2005. Following each visit, a written report must be sent to the home and the Commission for information. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 3 X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Oxberry Avenue, 25 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X 3 3 2 DS0000019142.V262671.R01.S.doc Version 5.0 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. 2. Standard YA9 YA23 Regulation 13 37 Requirement Staff must make sure that risk assessments agreed as part of care plans are completed. All accident and incident reports must be completed fully and copies of reports written following significant incidents must be sent to the Commission for information. A working shower must be provided for service users who choose not to use the bath. Original timescale of 30/06/05 not met. Staff must always make sure they ring the home if they cannot start a shift on time. The manager must complete her NVQ Level 4 qualification training. Yarrow must ensure that senior managers from within the organisation carry out monthly monitoring visits. Timescale for action 31/12/05 31/12/05 3. YA27 23 31/12/05 4. 5. 6. YA32 YA37 YA43 18 9 26 31/12/05 01/09/06 31/12/05 Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 20 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 YA23 Good Practice Recommendations The manager or deputy manager should check and countersign the record where large sums of money are spent on behalf of service users. Oxberry Avenue, 25 DS0000019142.V262671.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hammersmith Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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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