Inspection on 13/05/05 for Sudbury Care Homes 67 Sudbury Avenue

This inspection was carried out on 13th May 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sudbury Care Homes 67 Sudbury... 05/12/08

Sudbury Care Homes 67 Sudbury... 28/11/06

Sudbury Care Homes 67 Sudbury... 23/01/06

Sudbury Care Homes 67 Sudbury... 24/01/05

Sudbury Care Homes 67 Sudbury... 07/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Sudbury Care Homes 67 Sudbury Avenue Wembley Middlesex HA0 3AW Lead Inspector Andreas Schwarz Unannounced 13 May 2005 13:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Sudbury Care Homes Address 67 Sudbury Avenue Wembley Middlesex HA0 3AW 020 8922 5138 020 8922 7873 sudburycarehomes@ntlworld.com Mrs Danalutchmee Tyahooa 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) Mrs Danalutchmee Tyahooa Care Home Five Category(ies) of Learning Disability - Five registration, with number of places Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Five adults with Learning Disabilities (18yrs-65yrs). Date of last inspection 24th January 2005 Brief Description of the Service: The home is owned and run by Mrs Tyahooa. It is a three storey-terraced house in a residential area of North Wembley. It is situated about 5 minutes walk from North Wembley train station and from East Lane where buses are available to Wembley and to Harrow. There is parking for about two cars in front of the home and there is additional parking on the road. The home also states in its statement of purpose that it provides its own transport for service users to go shopping and to attend day centres.There is a large park opposite the home. There are some shopping facilities on the East lane and more extensive shopping facilities and local amenities are available in Wembley or in Harrow.The home is registered for five service users with learning disability. Accommodation is in single bedrooms. At the time of the inspection the home was fully occupied by five male service users. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in May 2005 and lasted for three hours. Residents have not been present during this inspection. The manager/provider and one member of staff assisted the inspector during this inspection. The inspector spoke to staff and viewed documents made available to him. The inspector would like to thank staff and manager for being so welcoming to the inspector throughout this inspection. Key standards were assessed during this inspection. What the service does well: What has improved since the last inspection? The home complied to three of the four requirements made at the previous inspection and has started working towards completion of the fourth requirement. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents are encouraged to be involved in the assessment process and their needs have been assessed appropriately. EVIDENCE: The home has a detailed assessment procedure in place. The manger has assessed residents and the assessment is very comprehensive. The manager informed the inspector that once a suitable resident has been assessed, the home offers a minimum trial period of six weeks; this can be extended up to three months if needed. Service users’ information from previous placements is available for information. The assessed needs are included within the care planning process. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6; 9 The home has good, comprehensive care plans and risk assessments in place. Residents are encouraged to take an active part in the care planning and risk assessment process. EVIDENCE: The inspector viewed two care plans during this inspection, both documents have been judged as very comprehensive and detailed. Needs, likes and dislikes are recorded. The key worker is reviewing care plan goals monthly and a review is arranged every six months attended by the residents, families, and other professionals involved in the care of the resident. The home uses pictures and symbols to communicate the care plan with service users who have communication difficulties. The viewed care plans included regular weight monitoring and challenging behaviour guidelines. The home has very detailed risk assessments in place. A wide range of risks has been assessed and risk assessments viewed by the inspector have been reviewed on a six-monthly basis by the manager/proprietor. Risk assessments are clearly written and give helpful guidelines for staff to follow if needed. Previous inspection required having a risk taking policy in place, which has been made available to the inspector. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 10 Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13; 14; 17 Service users living at the home access the community regularly and spend their spare time undertaking appropriate activities made available by the home. Residents are very active during the day and in their spare time. Residents receive a well-balanced diet and healthy diet EVIDENCE: The inspector viewed daily records made available to him; it was evident that residents access the local community regularly. Activities offered are Gateway Club, gym, pub, cinema, walks, etc. The home uses pictures to communicate choices given by the home and the resident can pick a picture to inform staff of his choice. The manager informed the inspector that service users are well known by neighbours and the home has good relationships with neighbours and members of the public. Service users are involved in household tasks such as cooking, cleaning and washing up. Each resident has a task delegated and the rota is displayed in the kitchen. In addition to this the home offers skill training such as road safety, which has been documented in residents care plans. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 12 Residents are offered holidays annually and pictures of these are displayed throughout the home. Service users receive a well-balanced diet. Menus are discussed in residents meetings and service users are encouraged to make a meal choice. The home documents if service users choose a meal different to the one recorded on the weekly menu. A dietician is involved with two service users and the home promotes a low calorie diet where possible. Service users dislikes are documented on the weekly rota. Fridge/freezer temperature is recorded on a daily basis. Fruits and snacks are available throughout the day. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19; 20 Resident’s health and emotional needs are met; the home involves clinicians as and when needed and service users attend health appointments regularly. Service users medication administration is of good standards, however the home is required to do some additional work for full compliance. EVIDENCE: The inspector viewed service users health records and it was evident that residents have regular health checkups, dental visits, dietician visits and other health care professional visits. The manager informed the inspector about the very good relationships with professionals at the Brent Learning Disabilities Team, providing access to psychologist, speech and language therapist, and occupational therapist, ect. Residents are registered with a local GP practice and can receive medical appointments in the privacy of their home. The home’s medication cabinet is lockable and located in the homes office. All staff have been trained and signatory list was made available for inspection. The home has a medication policy in place, but the inspector informed the manager that further work will be required and Royal Pharmaceutical Guidelines must be followed. None of the residents living at the home selfadministers medication and the home currently does not store and controlled drugs. The manager informed the inspector that recently there had been a visit by the dispensing pharmacist and she is currently awaiting the report. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 14 Residents’ medication has been reviewed by the GP and one service user has had his medication reduced. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22; 23 The home takes complaints seriously and service users are encouraged to voice their views in residents meetings and other forums offered to them. Service users are protected from abuse, neglect and self-harm EVIDENCE: The home has a robust complaints policy in place; the policy is displayed in different areas throughout the home. The complaints policy is available in pictures and symbols and states different ways of complaining, using a tape, in writing with pictures, etc. Relative feedback forms state that relatives have received the homes complaints policy. There were no complaints recorded since the last inspection. The inspector viewed the homes adult protection procedure, which follows Brent’s POVA guidelines. The home has a wide range of policies in place to protect vulnerable adults from abuse, such as whistle blowing, Challenging Behaviour, residents finances, control and restraint, etc. All staff with the exception of two attended Brent’s POVA training; staff the inspector has spoken to confirmed this. The remaining two staff are said to attend the POVA training scheduled for the end of May 2005. The manager is appointee for four of the service users; benefits are paid directly into resident’s accounts. The inspector audited one service user’s account, which was in order. Service users’ money is locked away and can only be accessed by designated staff. The manager checks finances every two weeks. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Residents are living in a nicely decorated and well-maintained home. There is adequate space for residents to socialise and to be on their own if they choose to. EVIDENCE: Sudbury Care Home is three-storey terraced home. The ground floor comprises of large living room, kitchen, toilet, and dining room with access to the garden. Three bedrooms and bathroom/WC is located on the first floor. There are two additional bedrooms and bathroom/WC on the second floor as well as the office and sleep-in arrangements for staff. The home is well maintained and is free of any offensive odours. The home is in easy access of a large park and bus routes to Harrow and Wembley. Furnishing is of domestic character and of good quality. The inspector recommends having more pictures displayed after consultation with residents. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 A stable and well-trained staff team supports Service users and needs of residents are well cared for. EVIDENCE: The inspector spoke to staff, manager and viewed training records. The home’s induction form is very detailed and deals with service users needs, support and administration in-depth. It is recommended that induction forms are signed and dated after completion. The inspector viewed the training attendance list displayed in the office and it was evident that three staff currently attend their NVQ training. In addition to this, the home offers compulsory training such as First Aid, Health and Safety, Manual Handling, etc. The manager informed the inspector that the home has access to an outside training organisation for additional training if and when required. Training records informed the inspector that all staff has been trained to NVQ Level 2 in Care. Previous inspections required having a training and development plan in place, the home has started work on this requirement and work must be completed. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 18 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; 42 Service users, visitors and staff are encouraged and have the opportunity to voice their views about the home through different forums offered to them. Residents are living in a safe and well-maintained home. EVIDENCE: The inspector viewed last years annual development plan, which was detailed, and it was evident that residents, visitors and staff are given different opportunities to voice their views about the service and service provision. The inspector viewed residents, relative and staff surveys/questionnaires, which were very positive about the home and service provided. The manager informed the inspector that the annual development forms part of the agenda for residents meetings; staff the inspector has spoken to confirmed this. The inspector recommends having a comment/compliment book available. The home has robust policies of Infection control, COSSH and Health & Safety in place. COSSH items were found to be locked away. All certificates such as gas, electrical appliances, electrical installation, etc. are in place and valid. The Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 19 manager has a list of when these certificates needing to be renewed in front of the Health& Safety file, this is good practice. Clear fire evacuation guidelines are in place and the home maintains records of regular fire drills, fire point checks and fire equipment checks to a very good standard. It was evident that the most recent fire training was in September 04 and has been attended by all staff. The fire risk assessment was viewed by the inspector, was judged as being current and up-to-date. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Sudbury Care Homes Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement The manager is required to up date the homes medication policy following Royal Pharmaceutical Guidelines. The manager must record the date of opening liquid medication. A training and development plan must be put in place for the home and individual staff. Timescale for action 30/06/05 2. 3. YA20 YA34 13(2) 18(1) 31/05/05 30/05/05 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 YA24 YA39 Good Practice Recommendations It is recomended to hang more pictures in the lounge after consulatation with service users. The inspector recomends to have a comments/compliments book in place. Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow, Middlesex HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sudbury Care Homes G62 G11 S17501 Sudbury Care Homes V224314 130505 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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