Inspection on 28/11/06 for Sudbury Care Homes 67 Sudbury Avenue

This inspection was carried out on 28th November 2006.

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 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... 23/01/06

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 67 Sudbury Avenue Wembley Middlesex HA0 3AW Lead Inspector Andreas Schwarz Key Unannounced Inspection 28th November 2006 08:00 Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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 Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sudbury Care Homes 67 Sudbury Avenue 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 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 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 Ltd and has a second home in Stanmore. The home situated about 5 minutes walk from North Wembley train station and 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 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. Charges and fees can be obtained from the registered manager on request. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place in November 2006 and lasted six hours. The inspector spoke to three residents, the registered manager, the deputy manager and one senior member of staff. The inspector had a tour of the premise and assessed two care plans, four staffing files and other records. The deputy manager Mr Tyahooa was available throughout this inspection. The inspector would like to thank residents, registered manager, deputy manager and support staff for the help and openness during this inspection. What the service does well: What has improved since the last inspection? The home has met all requirements and recommendations made during the inspection in January 2006. The home has employed two more staff and is now fully staffed. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 6 All staff have either completed or are in the process of completing their National Vocational Qualification in Care. The homes sexuality policy is now available in a service user-friendly format. Due to one service users moving to another home run by Sudbury Care Homes Ltd, the home is much quieter and service user informed the inspector to be happier living at the home. 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. The summary of this inspection report can be made available in other formats on request. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New prospective service users receive detailed information about the home, prior to being assessed appropriately, to establish if the home is able to meet the needs of new prospective residents. EVIDENCE: The home has had no admissions since the last inspection. The inspector viewed two service users files; both files had detailed assessments in place, which were undertaken by the previous deputy manager. Assessment information are included within service users care plan. All assessments have bee signed by the service users and their representative. The inspector viewed clear records of service users trial visits to the home and service users guide and statement of purpose are available and were displayed in rooms viewed by the inspector. Service users guide and statement of purpose are available in a user-friendly format. The home has an assessment policy, which has been read by all staff. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are of very good standard and service users involvement is evident throughout all care plans. Residents can choose where to go, what to eat and evidence of this was observed during this inspection. The home has detailed risk assessments in place and service users are involved in the review process. EVIDENCE: The inspector assessed two care plans during this key inspection, both documents are of very high standard and service users are involved within the assessment process. The residents’ advocate has attended all of the care plan reviews. Residents informed the inspector that they know about their care plan and that they meet regularly with their key workers. The inspector viewed clear records of these meetings. Care plans have been changed if service users needs have changed and goals are divided in short and long-term timescales. Assessed needs are included within the care planning process. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 10 Residents informed the inspector that they are able making decisions about their life; this was clearly demonstrated within the care planning processes and observed during this inspection. Service users families are involved within the care of service users and independent advocates are provided if family is not available. The home is managing service users finances and assessed records have been in order. The registered manager is regularly auditing service users accounts. Outgoing and incoming payments are clearly recorded and service users are encouraged to sign their account sheets. The home has a risk assessment policy in place and detailed risk assessments have been viewed. Risk assessments are assessed during care plan reviews or if needs are changing. Service users are involved in the review process and are encouraged to sign their risk assessments following a review. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is supporting residents to live a full, culturally appropriate and stimulating life. Residents can choose where to go, what to do and what to eat and are involved in the planning of activities. EVIDENCE: All residents living at the home attend daycentres or colleges. The home is providing transport and has a driver employed to assist residents attending daycentres and colleges. Two service users have a part time job at a local charity shop and residents attend computer classes in the evening. One resident is attending a performing arts class at a local college. Residents informed the inspector that they go regularly to the pub or have occasional Sunday lunches in a restaurant. Records viewed by the inspector confirmed this. All service users are on the electoral register and are Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 12 encouraged to vote. Adequate staffing numbers support residents during evenings and weekends. The staff team represents the cultural background of residents. Residents are able to go to their chosen place of worship. Residents did not go on annual holiday this year; this was due to the fact that all residents wanted to go abroad and the home needed to support residents in obtaining a passport. The registered manager informed the inspector that this has now been completed and residents informed the inspector that they would go to Disneyland Paris in the near future. The home has an excellent sexuality policy in place, which has been updated and is now available in pictorial form. Residents’ attend social clubs and go to discos to form and maintain relationships. Residents informed the inspector that they visit friends regularly; one resident was at his parental home during this inspection. All but one resident have their own key and residents’ rooms are locked if they are not at the home. If residents do not have or are not able having a key clear records of this are on file. The inspector observed staff interacting with residents in a professional and respectful manner. Residents informed the inspector of staff being friendly and listen to their problems. The inspector observed residents moving around freely. All residents have allocated tasks during meal times and are responsible for the upkeep of their rooms. The home has clear guidelines about smoking, alcohol and drugs in place. The home is providing a varied and healthy diet. Service users health care needs are taken into account and menus reflect allergies, low fat options, etc. Residents meet weekly to discuss the new menu, this is done with the use of pictures and all residents can choose according to their likes and dislikes. Cultural meals are provided and residents confirmed of being happy with the meals provided at the home. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health is managed appropriately and residents are encouraged to be as self-managing as possible. EVIDENCE: The home has detailed personal care guidelines in place, which are reviewed every six-month together with the resident. Daily records demonstrate that residents can get up or go to bed when they want. Residents have been dressed appropriately for their gender and the season and informed the inspector that they have chosen their own clothes. Staff supports residents in buying new clothes regularly and inventory lists are updated. Residents are involved in choosing new staff, prior staff being offered the post. The home has good links with Brent and Harrow Learning Disabilities Teams and specialist services are provided if needed. All residents have an allocated key worker and meetings are held regularly. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 14 All residents have their own GP. Optician, dentist and chiropodist services are accessed regularly to maintain service users health. The inspector viewed clear and detailed records of these visits in service users care plans. The home has a detailed medication policy in place, which is compliant with National Minimum Standards. Medication records assessed were of good standard and had no gaps. Service users medication is reviewed every six month by a health care professional. None of the residents living at the home self medicate. The home is using Boots MDS system, the inspector noted that not all medication start on the same day, and this should be reviewed. All staff has attended formal medication training. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to raise their satisfaction and dissatisfaction of services and support received at the home and are protected from abuse neglect and self-harm. EVIDENCE: The home has a complaints policy in place, which is easily available for residents, staff and visitors. Residents demonstrate a good understanding of whom to complain to. The home has received three complaints since the last inspection. Complaints have been documented and dealt with appropriately. The home is recording complaints in the complaints book and on a separate form this allows to record more detail of the complaint and the actions undertaken to resolve the complaint. The home has a Protection of Vulnerable Adults policy in place and Protection of Vulnerable Adults guidelines from hosting as well as funding borough are available. All staff attended Protection of Vulnerable Adults training. The home did not receive any Protection of Vulnerable Adults related allegations since the last inspection. The home has a Whistle Blowing, Violence and Aggression and separate Abuse policy in place. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a dated environment, which is clean and free of any offensive odours. Service users are encouraged to bring their personal possessions. EVIDENCE: Residents showed the inspector their rooms and around the building. Service users rooms are clean and no maintenance issues have been raised. The home has a maintenance and renewal programme in place. The home is nicely decorated, the inspector discussed with the registered manager that the lounge is in need for redecoration. The wallpaper is ripped in some areas and the inspector noted some small holes in the wall. The home was clean and free of any offensive odours; the laundry area is located outside the home. Service users are involved to clean the home. The home was very clean and tidy during the day of this key inspection. The home Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 17 has appropriate infection control and health and safety policies and procedures in place. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a diverse, experienced and skilled staff team. Appropriate recruitment policies and procedures protect residents from unsuitable staff. EVIDENCE: The home has employed eight staff, four staff have achieved their National Vocational Qualification in Care and four staff are working towards achieving their qualification. The home does not employ staff under the age of 18. The inspector observed staff supporting residents and noted staff to be patient and having good listening skills. The home has a recruitment policy in place, all new staff are issued with the General Social Care Councils Code of Conduct, induction pack and staff handbook. The inspector viewed four staffing files and all necessary documents such as two references, contract, proof of the right to work in the United Kingdom and Criminal Records Bureau checks were in place. Service users interview all new staff, which is recorded by one of the panel members. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 19 All staff have a detailed training and development plan, which is updated regularly. The home is providing mandatory such as manual handling, First Aid, Fire Safety; etc. and regular refreshers for existing staff is provided. The home is offering specialist training if needs of service users are changing. The deputy manager is currently undertaken his assessor qualifications and will act as a work based assessor for the home. The inspector informs the registered manager to apply for the Investors in People Award. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is skilled and qualified to manage the home. Residents are regularly involved and consulted in the running of the home. Residents Health and Safety is not compromised and safe working practices are in place. EVIDENCE: The registered manager/provider Mrs Tyahooa has been working at the home since it has been registered with the Commission for Social Care Inspection. The homes deputy manager is Mr Tyahooa. Mrs Tyahooa is a qualified nurse with management qualifications and Mr Tyahooa has National Vocational Qualification in Care and Management Level 4. The home is judged as being managed to very high standard, which is evident through regular staff Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 21 supervisions and appraisals, upkeep of records, feedback from service users and staff. Residents meet every two-month for a meeting. The home has a service development plan and has undertaken surveys to produce an annual development plan for the coming year. The home should send the annual development plan to the Commission for Social Care Inspection once completed. Residents are very vocal and are involved in the running of the home. The home has a fire risk assessment in place, which has been reviewed. The fire equipment has been serviced (09/06), emergency lighting test (06/06) and previous visits by the London Fire and Emergency Planning Authority were satisfactory. The Landlords Gas Safety Certificate is valid until September 2007, The Portable Appliances Test Certificate is valid until June 2007, and the Electrical Installation Certificate is valid until June 2007. The home has been visited by the Environmental Health Department in May 2005 and the visit was satisfactory. The home has a range of Health and Safety relating policies and procedures in place Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.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 YA24 Regulation 23(2)(d) Requirement The registered manager must arrange to re-decorate the lounge. Timescale for action 31/03/07 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. 2. 3. Refer to Standard YA20 YA35 YA39 Good Practice Recommendations The home should ensure that all residents’ medication commence on the same day of the week. The home should explore and apply for the Investors in People Award. The home should send the annual development plan to the Commission for Social Care Inspection once completed. Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Sudbury Care Homes 67 Sudbury Avenue DS0000017501.V320040.R01.S.doc Version 5.2 Page 25 - 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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