Inspection on 13/06/06 for Westleigh Avenue

This inspection was carried out on 13th June 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westleigh Avenue 01/09/05

Westleigh Avenue 16/05/05

Westleigh Avenue 14/12/04

Westleigh Avenue 18/05/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Westleigh Avenue 45 Westleigh Avenue London SW15 6RJ Lead Inspector Adrian Gordon Unannounced Inspection 15th June 2006 10:00 Westleigh Avenue DS0000010237.V299562.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 Westleigh Avenue DS0000010237.V299562.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. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Westleigh Avenue Address 45 Westleigh Avenue London SW15 6RJ 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) 020 8788 2111 /4356 02087884356 www.thresholdsupport.org.uk Threshold Housing & Support Ms Lorenza Hosten Care Home 14 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 01/09/2005 Brief Description of the Service: Westleigh Avenue is a purpose built care home registered for fourteen people with learning disabilities, seven of whom may also have physical disabilities. It is owned and managed by Threshold Housing and Support. The building is single storey and is well designed for wheelchair users. All residents have their own bedrooms with a wash hand basin. There are four bathrooms in total consisting of: one assisted bathroom, two bathrooms with separate showers and one shower room. The home is situated in a quiet residential area close to the shops and facilities of Putney. Information about the service is available in the Statement of Purpose and Service User Guide. Information about fees was not made available, however residents are expected to pay towards holidays. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and completed over the course of one day. The inspection consisted of examination of records, tour of the premises, observation of care practice, talking to three residents, five staff and the manager. Two feedback questionnaires were received from relatives. What the service does well: What has improved since the last inspection? What they could do better: The high turnover of staff at the home must be looked at and permanent vacancies recruited into. Although agency staff spoken to during the inspection were committed to their role, the dependence on temporary staff makes it difficult to ensure consistency and to build an effective team. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 6 Records kept at the home were not well organised and information was difficult to find. The manager and staff should look at making filing systems clearer and archiving old and out of date information. In order to protect residents, all staff, including agency, must be made aware of the procedures for the Protection of Vulnerable Adults. Medication records must be written accurately and any gaps properly explained. More work must be carried out to ensure that the rear garden is cleared of weeds and made accessible to residents. Staff must be more creative with food menus to encourage residents to have a healthy and nutritious diet. 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. Westleigh Avenue DS0000010237.V299562.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 Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents needs are appropriately assessed prior to admission which ensures staff are aware of how to meet their needs. EVIDENCE: There has not been a new admission to the home recently, however current resident files show that assessments are carried out and reviewed as necessary. These assessments cover a wide range of needs, including physical, social, emotional, health, psychological and cultural. A service user plan is developed from this assessment. A procedure for referrals and admissions is in place. Copies of each resident’s contract and tenancy agreement were seen to be kept on file. The recent Quality Assurance audit confirms that a copy of this is held by residents. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff are supported in meeting residents needs through the use of an effective care planning system. EVIDENCE: Resident files showed that all residents have a support plan which is signed and dated. These contained good information and goal setting though there was no information regarding sexuality. Goals are monitored on a daily basis. One residents had a ‘personal passport’ which had been developed by a Speech and Language Therapist. This was an excellent document about the resident, being clear and simply written using photos to make it easier to understand. Risk assessments are in place for residents and these were up to date and there was evidence of review. A risk assessment for one residents bed rail equipment is in place following a requirement at the last inspection. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 10 Resident files were not well organised and information was sometimes difficult to locate. The manager and staff should consider how best to reorganise filing systems to ensure useful and required documents are easily at hand. One residents file contained ‘feelings’ photographs which helped staff to understand the residents mood. Another resident had good information about how best to communicate with them. Minutes from resident meetings showed that they are encouraged to make decisions and give opinions, however it is the more able residents who usually take an active part. The home must develop different forms of communication which allow all residents to make choices and decisions. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents have the opportunity to take part in appropriate activities of their choosing which allow for personal development. EVIDENCE: Residents and staff were both positive about the activities which are undertaken at the home. Most residents attend a day centre, although two have made a choice not to. A minibus, which is shared with other Threshold homes, is available for use if needed. Holidays are discussed at resident meetings and one group recently went to Clacton for a week. One resident said that the TV in the lounge was too small to see when the room was busy. They agreed to bring this up at the next resident meeting. Residents are supported to access community facilities such as the local shops or church. One to one funding is provided by the local authority for residents with higher needs to enable them to go out locally. Relatives and friends are able to visit the home and a phone is available for use if needed. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 12 When residents returned from the day centre, staff were observed to talk appropriately with them and to provide support as needed. One resident confirmed that they were able to go to their room and be on their own if they chose to. Two residents were able to comment that they thought the food was ‘ok’. Minutes from the last resident meeting also showed that residents were happy with the food. A large amount of tinned and frozen food is kept in the stores and only small amount of fresh produce kept in the fridge. A four weekly menu was in place which showed a variety of meals but when the menu was last reviewed in October 2005 no changes were made. This was agreed by residents, however, staff must do more to promote new and healthier options. In one storeroom there was a cupboard full of tubs of margarine, one of which was out of date. The store room was quite warm. This is a serious risk to residents health and more care must be taken with stock control and storage. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good support is on place to meet residents health needs. EVIDENCE: One resident confirmed they are able to make choices about how they prefer to live, for example choosing what to wear or having alternative food if they don’t like what is on the menu. Many of the residents have complex health needs and staff demonstrated a good understanding of individual requirements. Evidence of input from healthcare professionals was seen. These include psychologists, speech and language therapists, district nurse and hospital consultants. Information in residents files about health needs was of a good standard. The medication folder showed example signatures for each member of staff responsible for its administration. Evidence was seen that a pharmacist regularly visits to assess the storage and recording system. Medication profiles are in place for each resident although one of these did not have a photo. One medication for a resident had not been signed for on one particular day. It was not clear why this was and staff were not able to explain. On two occasions Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 14 9pm had been written as 09:00 on the Medication Administration Record (MAR) sheet. Staff must ensure that all MAR sheets are filled in and any gaps explained. Care must be taken to ensure times are written accurately. Recently staff supported a relative with funeral arrangements following the death of a resident. This was handled sensitively and with respect. The relative fed back that staff at the home ‘helped so much’ and that the care had been ‘excellent’. Residents were also involved in a wake at the home following the funeral. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. In order to protect residents all staff must be made aware of the procedures for the Protection of Vulnerable Adults. EVIDENCE: There is a complaints policy at the home which has been made easier for residents to understand with the use of pictures. This was also seen on the wall of the dining room. There has been one complaint since the last inspection. This was seen to have been looked into and recorded appropriately. The Protection of Vulnerable Adults procedures seen were dated January 2001 and according to training records only two staff have completed POVA refresher training in the last year. The manager has subsequently said that there are up to date local and Threshold POVA procedures located elsewhere in the home. It is vital that all staff are made aware of the location and contents of these procedures. Resident finances are checked daily. The system used ensure that residents are protected from financial abuse. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff ensure the environment is kept clean and homely despite a high level of wear and tear. EVIDENCE: There is a high level of wear and tear in the home and this makes it difficult to maintain furnishings and decoration. However, the home was seen to be clean and hygienic, and communal areas were made homely with the addition of pictures and plants. A ceiling track has been added to the small lounge to assist disabled residents if needed. An internal courtyard is accessible to residents and part of the rear garden has been cleared to make a vegetable and flower patch. Much of the rear garden remains overgrown and unusable. One of the bathrooms was out of use due to a problem with the floor. This must be repaired at the earliest opportunity. Staff also commented that the heating had still not been turned off. This was making some rooms very warm, for example the small lounge. In one bathroom a mirrored door needed fixing to a cupboard and the light fitting was very dirty. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 17 Resident bedrooms were suitable for their needs and showed personal touches with posters and pictures. One resident showed me how they were able to operate the door using a remote control system as it was difficult for him to do it manually. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staff are well informed about the needs of residents, however a high level of agency usage makes it difficult to provide a consistent level of care. EVIDENCE: The manager keeps recruitment records for staff at the home. These included references, Criminal Records Bureau Disclosures (CRB’s), copy of passport and photos. However, not all files contained a photo and two CRB’s were carried out through an agency rather than Threshold. The home makes use of a high number of agency staff, although most of these have been working there regularly and have a good understanding of the routines and resident needs. Feedback from agency staff on the day was mixed. One agency said that they feel supported and receive supervision, but another staff, who worked regularly at the home, said that they have no formal supervision. The registered person must ensure that vacant posts are recruited into to reduce agency use and provide better consistency of care to residents. During the day, three residents were observed to be at home but interaction from staff was limited. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 19 All staff have individual training records which show staff receive induction and training in line with the Learning Disability Awards Framework. Core training such as manual handling, food hygiene and medication administration is being undertaken. The manager confirmed that NVQ3 training is ongoing although progress is slower than she would like. Westleigh Avenue DS0000010237.V299562.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Good monitoring systems mean that the aims and objectives of the home are constantly reviewed and residents views taken into account. EVIDENCE: The manager has many years experience working at Westleigh Avenue and demonstrated a good awareness of the needs of residents. Staff fed back that they felt supported by the manager. Resident meetings take place regularly and minutes show good involvement. At the last meeting in May residents were reminded of the Whistleblowing policy and discussed their holiday plans. Threshold Support has recently undertaken a comprehensive Quality Audit at the home which links in with the National Minimum Standards. Monthly monitoring reports showed that there is consultation with staff and service users Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 21 Health and safety checks in the home are generally up to date, including regular fire alarm system checks and fire drills. However, the fire risk assessment must be updated and the results of the Legionella test on 25/10/05 confirmed. Westleigh Avenue DS0000010237.V299562.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 1 2 3 4 5 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 X 3 X X 2 X Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 YA7 Regulation 12(3) Requirement Timescale for action 15/08/06 2 YA17 3 YA20 4 YA23 5 YA24 The registered person must ensure that, where possible, all residents are enabled to communicate their wishes and feelings with regard to the care they receive. 16(2)(g)(i) The registered person must ensure that the menu promotes healthy and nutritious food and that the storage of food items is monitored to ensure out of date items are discarded. 13 (2) The registered person must ensure that there are no unexplained gaps in the Medication Administration Records, that times are written down accurately and that all medication profiles have a photo of the resident. 13(6) The registered person must ensure that all staff are aware of and trained in the Protection of Vulnerable Adults Procedures. 23 (2) The registered person must ensure that all maintenance issues noted in the Environment section of this report are addressed and that the heating is properly controlled in the DS0000010237.V299562.R01.S.doc 31/07/06 31/07/06 31/08/06 15/08/06 Westleigh Avenue Version 5.2 Page 24 summer. 6 YA28 23(2)(o) The registered person must ensure that external grounds are properly maintained and suitable for residents use. The registered provider must ensure that agency staff usage at the home is kept to a minimum. The registered person must ensure that all staff have an up to date CRB check through Threshold and that there is a photo on file of all staff working at the home. The registered person must ensure that the fire risk assessment is updated and that the results of the Legionella test carried out on 25/10/05 are confirmed. 31/08/06 7 YA33 18 31/08/06 8 YA34 19, Schedule 2 31/07/06 9 YA42 13(4)) 31/07/06 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 Refer to Standard YA6 Good Practice Recommendations The registered person should ensure that resident files are reorganised so that useful and required documents are easy to locate. Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Westleigh Avenue DS0000010237.V299562.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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