CARE HOME ADULTS 18-65
Oxberry Avenue, 25 Oxberry Avenue 25 Oxberry Avenue Fulham London SW6 5SP Lead Inspector
Jacqueline Derbyshire Unannounced Inspection 23rd July 2007 09:30 Oxberry Avenue, 25 DS0000019142.V338124.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.V338124.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.V338124.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.V338124.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th November 2006 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. The weekly charge for Oxberry Avenue is £ 1165.40. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday 23rd July 2007; the inspector spent 4.00 hours visiting the home. The Inspector spoke with three of the people living at the home, a family member of one of the residents, the Deputy Manager and staff. The Inspector checked the care records of two residents; two of the residents finance records and all medication records. Four of the residents bedrooms were looked at and all communal parts of the home. The home provides a good standard of accommodation that was seen to be clean and tidy on the day of this inspection. 12 of the 14 requirements that were set November 2006 have been met; 5 new requirements have been made from this visit, and one good practice recommendation. There are health and safety issues at Oxberry Avenue that require the Managers attention. What the service does well: What has improved since the last inspection?
A shower is available for residents who choose not to use the bath. The manager will complete her NVQ Level 4 qualification training before the end of 2007. The Manager has liaised with the pharmacy to make sure that the information written on a all residents dossett box’s corresponds with MAR sheets. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 6 The Manager had implemented into two residents care plans the death and dying policy making sure that their wishes will be carried out. The Manager checks that any students doing a placement at the home have got a CRB disclosure. The Manager has ensured all staff have completed first aid training and there is a member of staff on duty for all shifts that has completed first aid training. The Manager has made sure all staff working at the home are up to date in mandatory training including first aid, food hygiene, POVA and medication. All frozen food packages that have been opened have a date opened and use by date written on them. Containers are provided to keep dry foods in that have been opened. There is a new boiler in the utility room. 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
Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Oxberry Avenue, 25 DS0000019142.V338124.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.V338124.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): Standards 2 and 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home unless a full needs assessment has been undertaken. EVIDENCE: The Inspector 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 Manager to liaise with the Local Authority to request a review for a resident who has not had any input from them to ensure care package is relevant. Oxberry Avenue, 25 DS0000019142.V338124.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 6,7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service involves individuals in the planning of care that affects their lifestyle and quality of life. EVIDENCE: The Inspector looked at two residents files that were comprehensive and had care plans that show how the home is going to meet the individual’s needs. Review records were all up to date with records showing how aims will be met. In discussion with a relative they told the Inspector they were happy with the care and support provided to their relative. The Inspector looked at two (PCP’s) and discussed them with the Deputy Manager and staff. The staff are becoming familiar with the (PCP) procedures and the Inspector discussed the progression with them in the home. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 11 None of the residents look after their own finances and support is given from key workers. The Inspector checked the financial transactions and monies kept for two residents and there are issues regarding the financial transactions being up to date and the correct balance showing. The Manager must make sure that all transactions are recorded and staff complete the financial transactions forms immediately after the purchase of goods or any other financial transaction on behalf of a resident. The Inspector saw risk assessments in the two files that were comprehensive and up to date. One of the residents has had episodes of challenging behaviour, the Manager and staff dealt with the problem extremely professionally and liaised with the relevant professionals and the source of the problem was eliminated. There is a requirement that the individual concerned has a review by the placing Local Authority to make sure that the relevant care package is being provided. There is a requirement that the fire evacuation risk assessment is completed as recommended by the (LFEPA). Oxberry Avenue, 25 DS0000019142.V338124.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. People who use the service have the opportunity to develop and maintain important personal and family relationships. EVIDENCE: All of the residents have an activity plan that was written in their files and also on the notice board in the kitchen/dinning room. The residents all attend different venue’s in the local community where they participate in activities. The Inspector was told that all of the residents had enjoyed a holiday this year the latest being in Wales. The daily record books looked at had entries that showed that residents had a good time. The Manager makes sure that all residents are supported daily to go out into the community and participate in activities they enjoy. The Inspector was told by the Deputy Manager that family and visitors are welcome at Oxberry Avenue, on the day of the Inspection a family member of one of the residents was visiting. The PCP’s that the Inspector looked at had photographs of family and friends visiting the home. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 13 In discussion with the Deputy Manger the Inspector was told that one of the residents enjoys going to church on a Sunday morning. There is a TV, DVD player and music centre in the lounge. The Inspector looked at the weekly menu and the meals being provided. There is a good variety and also different cultural dishes were offered. The menu had the names of the residents written on certain days that showed that residents are supported to prepare meals for the other residents. On the day of the Inspection two of the residents were seen to be helping themselves to drinks and snacks. Oxberry Avenue, 25 DS0000019142.V338124.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 18,19,20 and 21. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living at Oxberry Avenue have access to health care services both within the home and in the local community. EVIDENCE: All of the residents are assisted with personal care; this is done either in the resident’s bedroom or in one of the bathrooms. The relative of one of the residents told the Inspector that the assistance given to their relative is very good as the resident takes pride in their appearance. The Inspector looked at two residents files and each contained healthcare records. All of the individual’s regular health care checks had taken place, optical, dental and GP. The Inspector also saw records of appointments with psychiatrists, and other professionals. All of the residents are registered with the local GP. The Inspector checked the medication administration records for all of the people living in the home. Overall the Inspector felt that the standard of medication recording was good with all staff following the medication procedure. There is a requirement that when any medication packaging is opened the date opened must be written on it, and any old medication must be returned to the pharmacy.
Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 15 The Manager has implemented in the care plans the wishes of two residents concerning their wishes in regard to the death and dying policy. In discussion with the Deputy Manager the Inspector was told that family members of the other three residents have been liaised with but are not happy with discussing this policy at the present time. Oxberry Avenue, 25 DS0000019142.V338124.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 is clearly written and easy to understand, it is also available in different formats. EVIDENCE: Yarrow had a complaints procedure, adult protection procedure and a separate ‘whistle blowing’ policy and procedures. In discussion with the Deputy Manager and speaking to a resident’s family member the complaints procedure is known to all. The complaints procedure is on the wall in the hallway, the Manager will have to put an up to date copy in place, as that copy is out of date with the information regarding the Commission. There have been no complaints in the last 12 months at the home. The Inspector checked two of the resident’s finances and they did not have all financial transactions recorded that meant the correct balance of money was not in the residents secure money tin. In discussion with the Deputy Manager the Inspector was told that the residents had been on holiday and the financial transaction records had not been up dated. The finance records for all of the residents must be checked by the Manager and Deputy Manager regularly to make sure all records are correct. Oxberry Avenue, 25 DS0000019142.V338124.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. The people living at Oxberry Avenue are encouraged to personalise their bedrooms. EVIDENCE: The Inspector had a full tour of the home and four of the resident’s bedrooms were seen. Each of the bedrooms had photographs, pictures and was very personalised. A relative of one of the residents told the Inspector that they were happy with the house and had no concerns regarding the environment. There is a garden at the back of the home that looked pleasant for the residents to sit outside. There is a new boiler in the utility room that was a requirement from the last Inspection. The home was clean and tidy; the Inspector was told that a cleaner comes to Oxberry Avenue once a week for 4 hours to do the communal areas. Oxberry Avenue, 25 DS0000019142.V338124.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 32,33,34 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people living at Oxberry Avenue. EVIDENCE: The Inspector looked at the staff rota; there are adequate staff on duty at all times that ensures all of the residents needs will be met. The Inspector checked the training and development records and also had discussions with staff. Training is up to date for all staff and in discussion with the Deputy Manager arrangements had been made to make sure all staff attend the training required from the last Inspection in November 2007, all staff are now competent in first aid and the Manager makes sure there is a member of staff on duty on all shifts. There is a requirement that all staff have refresher training in moving and handling. The ratio of staff having completed NVQ’s is 80 with two staff at present doing NVQ level 2. The Human Resources team based at Yarrow head office carries out all recruitment. CRB records were checked and all staff has up to date checks completed. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 19 The Inspector checked supervision records of two staff that were seen to be up to date; both had also had an annual appraisal. In discussion with the Deputy Manager and a member of staff the Inspector was told all staff have regular monthly supervision. Oxberry Avenue, 25 DS0000019142.V338124.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 adequate. This judgement has been made using available evidence including a visit to this service. The Manager is qualified with the relevant skills and experience to run the home. EVIDENCE: In discussion with the Manger the Inspector was told that she will have completed the Registered Managers Award (RMA) by the end of the year 2007. The Manager has worked in social care for many years and has lots of experience. The Manager must audit records as the Inspector looked at some records that were difficult to read and some records did not have a date on them. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 21 The Inspector 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. One of the resident’s family told the Inspector they were happy with their relative living at Oxberry Avenue and that they had no worries or concerns. Yarrow collates all of their quality assurance information and produces a document annually to show outcomes of their audits. There have been two visits from the London Fire Emergency Planning Authority (LFEPA) since 2005 where a recommendation was made that the risk evacuation assessment for the home was not satisfactory. The Inspector could not see a revised risk assessment for the home; the Manager must make sure this has been completed. The water temperatures are varied in some parts of the home some to hot others to cold the Manger must get the temperatures set correctly. The Inspector looked at the training and development of staff working at the home, the Manager must make sure that all staff are up to date with moving and handling training. Oxberry Avenue, 25 DS0000019142.V338124.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 x 2 3 3 2 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 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 3 34 3 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 x 3 x 2 2 x Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA3 Regulation 15 Requirement The Manager to liaise with the Local Authority to request a review for a resident who has not had any input from them to ensure care package is relevant. This requirement was set originally 8th November 2006 All medication to have date opened written on them. The Manager to make sure all old medication is returned to the pharmacy. All records of financial transactions undertaken for a resident should be recorded and the correct balance written on the financial transaction records. This requirement was set originally 8th November 2006 The Manager to audit records to check legibility and make sure there are dates written on them. The Manager to complete a fire evacuation risk assessment as recommended by the (LFEPA). The Manager to make sure all
DS0000019142.V338124.R01.S.doc Timescale for action 23/08/07 2 YA20 13 23/08/07 3 YA7 YA23 13 23/08/07 4 5 6 YA41 YA42 YA42 17 13 13 23/10/07 23/08/07 23/10/07
Page 24 Oxberry Avenue, 25 Version 5.2 7 YA42 13 staff are up to date with moving and handling training. The Manager to make sure all water outlets are set at the correct temperature. 23/08/07 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 YA22 Good Practice Recommendations The Manager to update the complaints procedure in the hallway as the information on the Commission is out dated. Oxberry Avenue, 25 DS0000019142.V338124.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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
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