Inspection on 11/04/05 for Oxberry Avenue, 25

This inspection was carried out on 11th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 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 01/11/05

Oxberry Avenue, 25 16/11/04

Oxberry Avenue, 25 10/05/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

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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 Fulham London SW6 5SP Lead Inspector Tony Lawrence Announced 11 April 2005 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. OXBERRY AVENUE Version 1.10 Page 3 SERVICE INFORMATION Name of service Oxberry Avenue Address 25 Oxberry Avenue, Fulham, London SW6 5SP 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) 020 7736 2427 Yarrow Housing Limited Ms Georgina Frances Morgan Care Home 5 Category(ies) of Learning Disabilities - 5 registration, with number of places OXBERRY AVENUE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/11/04 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 Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on Monday 11th April 2005 from 09:30 – 14:30. The Inspector spoke with service users and staff, checked care records and toured the premises. Three relatives returned confidential questionnaires and their comments are included in the report. Four of the nine requirements made after the last inspection have been met. Five requirements are repeated in this report. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. OXBERRY AVENUE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection OXBERRY AVENUE Version 1.10 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 standard(s) 2 and 3. The care needs of people living in the home are well assessed and recorded and good guidelines have been produced for staff on supporting individuals. EVIDENCE: The home has introduced a system of Person Centred Planning for people living in the home. The Plans are clearly focussed on the needs and aspirations of each service user. The Inspector looked at the plans for three people. Two of the plans were completed very well and included clear goals for the person. Some good work has been completed to prepare for the third plan, but there is a need to make sure that clear goals are included. In preparing for the Person Centred Planning meetings, staff have made excellent use of photographs of service users, significant people, places and events to make the information more accessible to people living in the home. All five people living in the home have lived together for some years and original care needs assessments and other reports have been archived. The local authority monitors the care of each person living in the home and the Placements Officer organises regular reviews, involving the service user, their relatives, staff and other significant people. As well as looking at how care needs are met, the review considers the overall suitability of the placement, as individual’s needs change. OXBERRY AVENUE Version 1.10 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 standard(s) 6, 7 and 9. Standards of care planning and risk assessment are good. Staff involve service users in making decisions wherever possible. EVIDENCE: The Inspector spoke with 5 staff and felt that they each had a good understanding of the care needs of each service user. This knowledge, and the experiences of other people working with service users, has been used to produce excellent individual guidelines for staff. The guidelines cover important times of the day (getting up, meal times, going out, evening routines and weekend activities) and detail the support needed by each service user. Staff gave the Inspector many practical examples of how they support people living in the home to make choices about their daily lives. From choosing what time they get up and go to bed, to what they wear and whether or not they take part in planned activities, staff were clear that part of their role is to promote choice and independence. The standard of risk assessment and risk management in the home is good. Risk assessments have been completed for each service user and all have been updated recently. OXBERRY AVENUE Version 1.10 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17. Service users are well supported to take part in a range of activities in the home and the local community. EVIDENCE: The Inspector looked at the care plans for three people living in the home. Each plan included a variety of activities, including dance classes, movement and drama sessions. A masseuse also visits the home to work with individual service users. The staff rota is arranged to enable each person to be supported with an activity at least once each day. Staff also work late day shifts to support people with evenings out to the cinema or social clubs. Staff told the Inspector that all five service users have had a holiday in the last year. Three people went on holiday in the UK and two people went abroad. Good risk assessments were completed on all five people before their holidays. Service users are also able to take part in leisure activities in the home, either in communal rooms or bedrooms. Three service users have regular contact with their relatives, including one person who stays with their mother three nights each week. Other relatives OXBERRY AVENUE Version 1.10 Page 10 visit service users in the home and staff said that they support contact by phone and in writing. One service user has a befriender from a local church who visits the home weekly. Staff support the service user to attend church each week where she helps the befriender with the Coffee Morning. Three relatives returned confidential questionnaires sent out as part of this inspection. All three people said that they could visit at any time and staff are welcoming. All three people also said that they were consulted about their relative’s care and informed of significant issues. One person added ‘I am very pleased with the care at Oxberry Avenue. My daughter is happy, I am happy and the staff are always kind. We all understand what is going on and I always know about changes’. OXBERRY AVENUE Version 1.10 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 standard(s) 18, 19 and 20 The health care needs of people working in the home are well met and staff work well with other agencies. EVIDENCE: Service users’ health care needs are well recorded as part of their care plans. Staff said that three people living in the home are able to meet their own personal care needs, but two people require some physical assistance. Both people have asked to be supported with their personal care only by female staff. This is not an issue as the staff team is currently all female. Each of the three care plans checked by the Inspector included a checklist detailing contact with health care professionals, including the person’s GP, optician and dentist. Detailed support guidelines developed for each service user include health care issues. A specialist epilepsy nurse provides epilepsy awareness training for all staff. Staff are not allowed to administer epilepsy medication until they have successfully completed certificated training provided by the nurse. Standards of medication management in the home are good. The home uses a Monitored Dosage System for all prescribed medication. Staff administer all medication and standards of record keeping are good. OXBERRY AVENUE Version 1.10 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 standard(s) 22 and 23. The home has a clear complaints procedure in an accessible format and service users are cared for safely. EVIDENCE: Staff said that although all five people living in the home have little or no speech, each person can make their needs, likes and dislikes known to staff. Yarrow has developed an excellent accessible complaints procedure, using Plain English, symbols and pictures. The Manager confirmed that there have been no formal complaints from service users, relatives or other people. Staff told the Inspector that there are occasional disagreements between people living in the home but these are dealt with by staff at the time. These would be recorded in service users’ daily care notes, but would not be recorded as formal complaints. All three relatives who returned questionnaires said that they knew about the home’s complaints procedures. There is a need to provide more evidence that service users’ views are listened to and acted upon. The last inspection report included a requirement that service users are consulted as part of an independent quality assurance system and this still needs to be implemented. OXBERRY AVENUE Version 1.10 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 standard(s) 24, 25, 26,27,28 and 30. The home provides an excellent standard of private accommodation. There is a need to provide a new shower. EVIDENCE: 25 Oxberry Avenue is a terraced house in a residential area of Fulham, close to local shops and transport links. Threshold Housing Association owns the property. Accommodation is provided on the ground, first and second floors and the home is not suitable for people with a physical disability. On the ground floor there is a lounge, dining room, kitchen, laundry room and toilet with wash hand basin. There is also a small patio area to the rear of the home. Three of the five bedrooms are situated on the first floor and the other two bedrooms are on the second floor. There is a bathroom on the first floor and a shower and WC on the top floor. The staff office/sleep in room is also on the top floor. Since the last inspection all parts of the home have been redecorated to a good standard. Service users’ bedrooms are especially well decorated, comfortably furnished and highly individualised. OXBERRY AVENUE Version 1.10 Page 14 and shared One service user chooses to have a shower each morning and a second person prefers to use the shower, although staff said she will also use the bath on occasion. The shower room is located on the top floor and the water pressure is not good enough to provide a satisfactory shower. Although the Housing Association has tried to repair the existing shower this has not been successful. Yarrow must ensure that service users have use of a working shower. A requirement was made after the last inspection that a door lock must be fitted on one service user’s bedroom. This has not been done and the requirement is repeated. A service user from another home managed by Yarrow works as a cleaner at Oxberry Avenue for 2 hours a day, 3 days a week, cleaning communal areas. People living in the home clean and tidy their own rooms, with support from staff. Good standards of cleanliness and hygiene have been achieved. OXBERRY AVENUE Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 and 35. Despite a number of staff changes since the last inspection, good standards of care have been maintained. Bank workers known to service users are used to cover vacancies but there is a need to recruit more permanent staff. EVIDENCE: Since the last inspection three staff, including the Deputy Manager, have left the home. Bank staff known to people living in the home are used to cover vacancies. One of the home’s experienced Residential Support Workers is covering the Deputy Manager’s post. The Manager explained that filling the vacant posts is dependent on staff changes in other homes and this issue must be resolved as soon as possible. Criminal Records Bureau Enhanced Disclosures have been obtained for all staff working in the home and the visiting masseuse. The home was well staffed during this inspection and the staff team worked well together to make sure that service users took parting planned activities. Staff told the Inspector that they had regular supervision with the home’s Manager or Deputy Manager and NVQ training is available for all staff. OXBERRY AVENUE Version 1.10 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 40, 41 and 42. Standards of record keeping are good. There is a need to ensure staff are clear about the organisation’s policies and procedures for handling service users’ money. EVIDENCE: The requirement made after the last inspection that service users’ views are included in a verifiable quality assurance system is repeated. The Inspector checked the finance records for all five people living in the home. Use of service users’ money is well recorded by staff and receipts are obtained for each transaction. There is a need to ensure that service users do not pay for bedding and this money must be reimbursed. While Yarrow has developed all of the policies and procedures required to meet the National Minimum Standards, staff were unclear about the status of some policies. The Manager confirmed that some policies have not been finalised and this requirement is also repeated. No health and safety issues were noted. OXBERRY AVENUE Version 1.10 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 1 3 x 3 Standard No 11 12 13 14 15 OXBERRY AVENUE x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 3 x Version 1.10 Page 18 16 17 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x 2 2 3 3 x OXBERRY AVENUE Version 1.10 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 YA16 YA21 Regulation 23 15 Requirement A lock must be fitted to one persons bedroom door (timescale of 31/12/04 not met). The homes policy on death and dying must be finalised and implemented (timescale of 31/12/04 not met). Service users personal money must not be used to pay for bedding (timescale of 31/12/04 not met). An objective and verifiable quality assurance system that includes the views of service users must be introduced (timescale of 31/12/04 not met). The homes policies and procedures must be regularly reviewed and those in draft form should be finalised and implemented (timescale of 31/12/04 not met). A working shower must be provided for service users who choose not to use the bath. Permanent staff must be recruited to fill vacancies. Timescale for action 30/06/05 30/06/05 3. YA26 20 30/06/05 4. YA39 24 30/06/05 5. YA40 17 30/06/05 6. 7. YA27 YA32 23 18 30/06/05 01/09/05 OXBERRY AVENUE Version 1.10 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. 2. Refer to Standard YA2 Good Practice Recommendations Person Centred Plans for service users should include clear goals. OXBERRY AVENUE Version 1.10 Page 21 Commission for Social Care Inspection 11th Floor, West Wing 26/28 Hammersmith Grove Hammersmith 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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