Inspection on 15/05/08 for Oxberry Avenue, 25

This inspection was carried out on 15th May 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oxberry Avenue, 25 23/07/07

Oxberry Avenue, 25 08/11/06

Oxberry Avenue, 25 01/11/05

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 28/09/2008.

CARE HOME ADULTS 18-65 Oxberry Avenue, 25 Oxberry Avenue 25 Oxberry Avenue Fulham London SW6 5SP Lead Inspector Jacqueline Derbyshire Unannounced Inspection 15th May 2008 09:00 Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 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) info@yarrowhousing.org.uk Yarrow Housing Ms Georgina Frances Morgan Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 23/07/07 Date of last inspection Brief Description of the Service: Oxberry Avenue is a registered care home providing accommodation and personal care for 5 people with a learning disability. The Threshold Housing Association owns the property 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.V362977.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Friday 15th May 2008; we spent 4.30 hours visiting the home. We spent time talking to the deputy manager, staff and people living at Oxberry Avenue. We checked the care records of two people; all medication and finance records were looked at and were well recorded. All of the bedrooms were looked at and all communal parts of the home. The home provides a good standard of accommodation. The home was seen to be clean and tidy. We received two relatives’ surveys and discussed the home with two relatives; comments from the surveys will be included throughout this report. All of the eight requirements that were set 29/10/07 have been met; four new requirements have been made from this visit. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly charge for Oxberry Avenue is £ 1165.40. What the service does well: What has improved since the last inspection? The resident that did not have an allocated care manager has now and review records show that their (PCP) is up to date with reviews taking place. We looked at the medication administration records (MAR) and looked at the medication storage cupboard. All medication had a date opened on the label and there was no old medication stored. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 6 The financial transaction records were looked at and were seen to be recorded appropriately with the relevant balance in place for each person. The manager must audit the financial transactions on a regular basis to make sure all staff is following the correct procedure. We looked at records kept and the legibility has improved a lot, there is still some staff that needs to make sure that their writing can be read. All records looked at did have a date and signature on them. We looked at the fire risk assessment that was up dated and meets the recommendations set by the (LFEPA). We looked at training records for three staff and all three staff is up to date with mandatory training. We looked at the health and safety records for hot water temperatures; all outlets were set at the correct safe temperature and records looked at show that were checked on a weekly basis. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 8 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.V362977.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a statement of purpose that is specific to the individual home and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a service user’s guide. EVIDENCE: We looked at the Statement of Purpose and Service User Guide, both documents are up to date and relevant and include all of the relevant information for the people living at the home and for prospective people considering using the service. Each document can be provided in different formats if required. We looked at two residents files and records were in place that showed how the home would be suitable for each person. All prospective residents have their needs assessed with their aims and aspirations looked at to make sure the home is suitable and that staff are adequately trained to be able to meet them. All five residents have lived at Oxberry Avenue for a long time and the records of them visiting the home prior to moving in have been archived as recommended in a previous Inspection. The two files looked at had a signed agreement in place, the original terms and conditions contract was archived with all of the other long-standing original documents. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service will know and record the preferred communication style of the individual, and will use proven methods that enable the person to lead a full life that promotes independence and choice. EVIDENCE: Comments made by relatives of people who use the service. ‘The staff use initiative and imagination to motivate the people they look after enabling the people to pursue their special interests’. ‘Staff are very kind to my relative’. We looked at two residents files both had a comprehensive care plan. The care plans had a lot of information linking into the daily routine of the individuals, showing the individuals likes, dislikes their family and what activities they enjoyed doing. We were shown the Person Centred Planning (PCP) that are in pictorial formats and are used as an ongoing record. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 11 The preferred communication style was recorded in the two files looked at as not all of the residents can verbally communicate. We saw residents being assisted by staff who were asking the individuals what they would like to do not telling them. In discussion with a resident’s relative we were told that there daughter likes living at Oxberry Avenue. One of the residents made them self a drink in the kitchen; we were told that this is part of the individual’s aims to be able to prepare drinks for themselves. We looked at risk assessment records that linked into the care plan for any risk areas and how the staff were eliminating or minimising the risk. One of the resident has seizures and the information and records was very descriptive and well recorded with the actions necessary to make sure the individual does not become to distressed. There was a requirement that the fire evacuation risk assessment be completed as recommended by the (LFEPA), the record had been completed and contained all of the information required. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13,15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team help with communication skills, both within the service and in the community, to enable residents to fully participate in daily living activities. EVIDENCE: We looked at two residents files and care needs assessments. Both files contained a lot of information regarding the resident’s likes, dislikes, hobbies and leisure interests. We looked at daily records for the people staying at the home and there was information written daily about what activities an individual had done including shopping, eating out, and going for walks and attending any community centres. The manager makes sure that all residents are supported daily to go out into the community and participate in activities they enjoy. We were told by the deputy manager that family and visitors are welcome at Oxberry Avenue; on the day of the Inspection a resident was getting ready to go and spend the weekend with their family. The PCP’s that we looked at had photographs of family and friends visiting the home. Residents are encouraged to go on a holiday and records were seen that show holidays have been booked for this year. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 13 We were told that the home does a big weekly shopping for food but shop regularly for the food requested by the residents as they have different people with different cultural and religious dietary needs, there are also people that require special diets. The staff goes out to the shops daily with residents as residents enjoy going shopping for their food. Records of what residents had eaten were looked at and discussed with the staff. The Annual Quality Assurance Assessment (AQQA) form completed does go into detail about the different diverse needs of people using the service and how they try to provide a varied menu. We looked at the weekly menu that was in the kitchen that had a lot of different meal options and was also in a pictorial format. On the day of the Inspection one of the residents were seen to be helping them self to drinks and snacks. The manager must check that all frozen food is stored appropriately and any packages that have been opened have the date opened and use by date recorded. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health, nursing and dietary requirements are clearly recorded in each person centred plan and healthcare plan. EVIDENCE: We saw reports from social workers, occupational therapists, physiotherapists, psychologists and speech and language therapists. The reports each contained useful information and guidance for staff. In discussion with the deputy manager and staff on duty at this site visit it was clear that different levels of support are required but mainly full care support. All of the people who stay at Oxberry Avenue are registered with a GP. We looked at two residents files and both had a comprehensive health action plans in place, showing that all health checks including optical, dental and hearing check ups had been completed by the relevant professionals. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 15 We looked at the medication records kept at the home that were well recorded and accurate. The medication storage cupboard did not have any old medication stored, as now is the practice to record and send any outdate medication back to the pharmacy. We were told by the deputy manager that all staff have had medication training and are fully aware of the medication policy and procedure. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the NMS and regulations. The procedure is up to date and displayed on the notice board in the home but is not being given to residents’ relatives. EVIDENCE: Comments made by relatives of people who use the service. ‘I do not know the complaints procedure’. ‘ I would like a copy of the complaints procedure although I do not have anything to complain about at the moment’. We looked at the complaints file that had no complaints recorded in the last 12 months. The manager has made sure that the complaints procedure is up to date and on the notice board in the hallway. The manager must make sure that the complaint procedure is given to all residents’ relatives to use if there is a complaint or if someone wants to make a suggestion about the service. The complaints procedure is available in different formats including pictorial. There have been no safeguarding incidents at the home in the last 12 months. The Inspector looked at the finances of the two people staying at the home, the records were correct with receipts in place for any financial transactions made with the resident or on their behalf. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to personalise their bedrooms. All of the homes fixtures and fittings meet the needs of individuals and can be changed if their needs change. EVIDENCE: Comments made by relatives of people who use the service. ‘My daughter really likes her bedroom and has all of her pictures up on the wall’. ‘The home is cosy and comfortable just as a home should be’. We had a full tour of the home and all of the resident’s bedrooms were seen. Each of the bedrooms had photographs, pictures and was very personalised. There is a garden at the back of the home that looked pleasant for the residents to sit outside. The home was clean and tidy; we were told that a cleaner comes to Oxberry Avenue three times a week to do the communal areas. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. EVIDENCE: On the day of the Inspection there were 3 staff on duty including the deputy manager. We looked at rotas and sufficient staff was scheduled to be on duty on all shifts. We looked at records and information showing that all staff including bank staff has a full Criminal Records Bureau (CRB) Disclosure with relevant training and experience including first aid, food hygiene and challenging behaviour. The Human Resources department at Yarrow completes all recruitment with all relevant checks on prospective staff taking place before they begin employment. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 19 The manager is completing the Registered Manager Award and should have finished in November 2008. The manager keeps a training and development schedule for herself and the Annual Quality Assurance Assessment (AQQA) states that the manager undertakes regular training courses to update her knowledge. The ratio of staff having completed NVQ’s is 80 with two staff at present doing NVQ level 2. We were not able to look at supervision records; in discussion with the deputy manager and a member of staff we were told that not all staff have regular structured supervision. The manager must make sure all staff receive regular supervision to make sure that they are up to date with the organisations aims and objectives as well as their own. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. They work to continuously improve services. EVIDENCE: The AQQA showed that the manager will have completed the Registered Managers Award (RMA) by the end of the year 2008. The Manager has worked in social care for many years and has lots of experience. We looked at two residents files and each had quality assurance questionnaires in place. The residents had both been assisted by family members to complete the questionnaires. Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 21 We looked at a lot of records and documents, the legibility of records has improved however there are still a few staff who’s writing is difficult to understand. All of the records were up to date, relevant and did have a date and signature on them. We looked at two residents files and each had quality assurance questionnaires in place. The residents had both been assisted by family members to complete the questionnaires. Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. We were given the dates for all Health and safety checks in the (AQQA) that show they are all up to date. The fire alarm, water temperatures and fridge freezer temperatures were looked at were well recorded with no issues. There is an issue about frozen food storage. We looked at the fire risk assessment that was up dated and meets the recommendations set by the (LFEPA). We had a full tour of the home as written and the only issue is that the fire extinguishers have not had there annual maintenance check that was required to be done in April 2008. The deputy manager was liaising with the (LFEPA) to make sure that this was done imminently. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 22 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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x 3 2 x Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 13 Requirement The manager must make sure that all frozen food is stored safely to protect residents from food poisoning. Timescale for action 22/05/08 2 YA22 22 3 YA36 18 4 YA42 23 The manager must make sure 15/06/08 that all residents’ relatives have an up to date copy of the complaints procedure so they are able to use if required. The manager must make sure 15/08/08 that all staff have regular structured supervision meetings to ensure they are up to date with the organisations aims and objectives and their own. The manager must make sure 22/05/08 that the fire extinguishers have had the annual maintenance check as required. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 24 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 YA41 Good Practice Recommendations The manager must make sure that all staff is aware of the importance that their writing is legible. Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Oxberry Avenue, 25 DS0000019142.V362977.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!