Inspection on 23/01/06 for Sudbury Care Homes 67 Sudbury Avenue

This inspection was carried out on 23rd January 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 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... 13/05/05

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 Unannounced Inspection 23rd January 2006 09:00 Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 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 Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 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. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sudbury Care Homes Address 67 Sudbury Avenue Wembley Middlesex HA0 3AW 020 8922 5138 020 8922 7873 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) Mrs Danalutchmee Tyahooa Mrs Danalutchmee Tyahooa Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th May 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. The company is trading under the name of Sudbury Care Homes has just recently opened a second home in Stanmore. The home 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 disabilities and has currently one vacancy. Accommodation is in single bedrooms. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during a morning in January 2006. The registered manager Mrs Tyahooa was available throughout this inspection. The inspector spoke to one staff member during this visit. Unfortunately all residents have left to the day centre and the inspector was therefore not able talking to residents. Excellent records and documentation provided enough evidence to judge that residents are well cared for. The inspector would like to thank Mrs Tyahooa and the support worker for being supportive and helpful during this inspection visit. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 The home enables and encourages residents to make their own choice. EVIDENCE: The registered manager informed the inspector that all residents have their own room and front door key. One resident requires assistance when opening doors, which is recorded in the care plan. The registered manager is acting as an appointee for three service users; the inspector sampled two financial records, which were both found in order. One service user is looking after his own money, but staff supports him in budgeting his finances. The home has monthly residents meetings, which are clearly recorded. One service user has recently moved out of the home, due to being incompatible with the other service users living at the home, the resident was fully involved in this process. One resident has an advocate involved, the other residents have strong and regular family input. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 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 the following standard(s): 12; 15; 16 The home provides and offers a wide range of activities to service users. Residents are encouraged and supported developing and maintaining meaningful relationships. Residents are supported taking part in domestic responsibilities and are given the right to live as freely as possible. EVIDENCE: The registered manager informed the inspector that residents went to a Panto the day prior this inspection and records of this have been viewed by the inspector. Residents attend different daycentres, which are within or out of the borough. One service user is working at the day centre and receives payment for this. During the evening residents go to the Gateway Club, weekly computer or drama classes. If residents do not demonstrate interest of attending activities on offer the home provides in-house activities such as cooking, tabletop games, etc. All residents went for a one-week holiday to Centre Park in Sussex last year and pictures were available in the home. The registered manager informed the inspector that she is not aware of any sexual relationships residents may have. However residents have adequate opportunities of making relationships if they wish to do so. The home has an Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 10 excellent sexuality policy in place; the inspector recommended providing this policy in a user-friendly format. The home has a visitor policy in place and residents can be visited at all times; if out of hours visitors are asked to inform the home of this in advance. All but one resident have family input and there involvement is clearly demonstrated in care plans and other meeting relating to the service users. The registered manager informed the inspector that all residents have their own room and front door key. The home is supporting one resident to lock and unlock the doors; the other residents do this independently. The inspector assessed daily records and it is evident that residents are involved in domestic tasks such as cooking, cleaning, launder their clothes, etc. Residents can get up or go to bed whatever time they choose to do so, but the home will support residents if the time restrict service users activities. Records demonstrate that residents can spend time with staff or on their own if they wish to do so. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18; 20 The home is providing personal care and support according to service users wishes and preferences. The home supports residents appropriately in medication administration and the medication policy has been reviewed and updated as required in the previous inspection. EVIDENCE: All residents are registered with their own GP. Excellent health records demonstrate, that all residents regularly go to their GP, dentist, optician, psychiatrist, podiatrist, etc. All residents have individual physical health and nutritional guidelines in place. Spiritual needs are discussed and addressed in care plans. Residents receive regular health check ups. All residents have a designated key worker, who meets regularly with service users to discuss progress and records of this are available. Bathrooms and bedrooms can be locked from the inside and can be opened from the outside in case of an emergency. Personal care guidelines are available for residents and their preferences are recorded and clearly documented. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Residents are protected from abuse, neglect and self-harm. EVIDENCE: Previous inspections to the home provided evidence that residents living at Sudbury Care Homes are appropriately protected from abuse, neglect, etc. Residents living at the home are not all funded by Brent and the inspector recommends obtaining Protection of Vulnerable Adults guidelines from all funding authorities. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Residents live in a clean and odour free home. EVIDENCE: The home was clean and free from any offensive odours during this unannounced inspection. The laundry area is located in a lockable cupboard besides the main entrance and a dryer and washer of domestic character is available. None of the residents living at the home has any continence problems. There is no sluicing facility available at the home. The COSSH cupboards are located in the dinning room and have been locked during this inspection. The home has a detailed infection control policy in place. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32; 34; 35 A skilled and qualified staff team understands service users needs. Residents are protected by appropriate recruitment procedures from unsuitable staff. A skilled and well-trained staff team supports residents; all staff have a training development plan as required previously. EVIDENCE: The inspector viewed training records during this inspection; the home has currently two staff with NVQ in Care Level2 and two staff who work towards achieving this qualification. The deputy manager has achieved his registered manager award and NVQ Level 4 in care, and is currently doing his assessor award. All staff have been issued with the General Social Care Councils Code of Conduct and the home only employ staff over the age of 18. Sampled staffing files provide evidence that staff has been supervised regularly and each member of staff has a training and development plan and training needs are analysed. The home has a recruitment policy in place. Staffing files sampled by the inspector demonstrated clearly that the home undertakes all required employment checks. Staff the inspector has spoken to demonstrated knowledge regarding service users needs and enthusiasm about their work. The home provides specialist training such as epilepsy or challenging behaviour and staff attend regular team-meetings. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 15 Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 Residents live in a home, which is managed and run appropriately. EVIDENCE: The registered manager/provider Mrs Danalutchmee Tyahooa is a qualified nurse with over 20 years experience in a hospital setting. Mrs Tyahooa has achieved her registered manager qualification. The registered manager was not able to produce a job description for the manager post during this inspection and is required to do so. The registration certificate and a valid public liability insurance certificate were openly displayed. Staff expressed satisfaction regarding the support they receive from their manager. Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 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. 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 2 X X X X X X Sudbury Care Homes DS0000017501.V277448.R01.S.doc Version 5.1 Page 18 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 YA39 Regulation 8; 9; 10 Requirement The home must have a job description for the registered managers post. Timescale for action 28/02/06 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 YA15 YA23 Good Practice Recommendations The registered manager should provide the homes sexuality policy in a user-friendly format. The registered manager should obtain Protection of Vulnerable Adults guidelines from all funding boroughs. 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