Care Home: Mencap (Chasewood Avenue)

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What the care home does well The home provides consistently good outcomes for people. The statement of purpose clearly sets out the philosophy and objectives of the home. The home understands the importance of having sufficient information when choosing a care home. Admissions to the home are made on the basis of a detailed assessment. This ensures the best outcomes for people who live at the home. The home has continued to improve care plans so that they are more person centred. The home involves individuals in the planning of care that affects their lifestyle and quality of life. Risk assessments were found to cover all areas that affected the people`s daily life. Risks are managed positively to help people living at home to lead the life they want. The menu is prepared at a weekly meeting of people living at home. A variety of meals are provided that reflect the individual preferences of people who live at the home. Care plans outlined the support people require to maintain their independence when being supported with their personal care. Personal support is responsive to the varied individual needs and preferences of people who live at the home. People told the expert by experience that they "visited the doctor and when they are very poorly the doctor will come to the house." People are supported to access the healthcare they need. We found that records for the administration of medication were complete. People`s medication had been reviewed regularly to ensure their continued well being. The complaints policy is available in a pictorial format. People who live at the home are supported to share their concerns. The home has an open culture that allows people to express the views and concerns in a safe and understanding environment. People who live at the home told us that they could challenge and raise concerns about the way they were treated. People living in the home feel safe and well supported by an organisation that has their protection and safety as a priority. Training records confirmed that all staff has all the statutory required training. All staff receive relevant training that is focused on delivering improved outcomes for people.Mencap (Chasewood Avenue)DS0000010572.V356009.R01.S.docVersion 5.2Page 7A system is in place to monitor the quality of the service provided by the home. Ongoing quality assurance is carried out to make sure that the home provides improved outcomes for people. The registered manager makes sure that the safety risks to people living at the home and staff is identified. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff. What has improved since the last inspection? There were no areas for improvement identified at the last inspection. What the care home could do better: Two areas for improvement have been identified at this inspection. The registered persons should make sure the menu is available in a picture format. Menus need to be easy to understand so that people are able to make a positive choice about what they eat. The registered persons should make sure that a new cupboard be purchased for the person`s bedroom identified at the inspection. People need to have furniture that is safe and fit for purpose. CARE HOME ADULTS 18-65 Mencap (Chasewood Avenue) 3 Chasewood Avenue Enfield Middlesex EN2 8PT Lead Inspector Tony Brennan Key Unannounced Inspection 31 January – 8th February 2008 1:00 st Mencap (Chasewood Avenue) DS0000010572.V356009.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 Mencap (Chasewood Avenue) DS0000010572.V356009.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. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mencap (Chasewood Avenue) Address 3 Chasewood Avenue Enfield Middlesex EN2 8PT 020 8342 1568 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) www.mencap.org.uk Royal Mencap Society Paula Jean Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 specific service user who is over 65 years of age may continue to be accommodated in the home. This condition must be reviewed at such times as the specific service user vacates the home. Date of last inspection Brief Description of the Service: The home is a large detached house in a quiet road near Enfield. The home has three floors. On the ground floor there is the kitchen, lounge and laundry. There is also one large en-suite bedroom for a service user who uses a wheelchair. On the first floor there are five bedrooms and two accessible shower rooms. On the top floor there is a further bedroom and the staff office. The home is very comfortable and there has been a great deal of effort made to ensure the bedrooms are comfortable and reflect the tastes and preferences of the service users. There is a large, attractive garden to the rear of the house, which has seating and is used by the service users. The aims of the home are to affirm and enhance the dignity and self-respect of the service users and to pay due regard to their wishes and preferences. The service also aims to support the service users to share in and contribute to the community, and to lead an ordinary life with the assistance they require. The home is for six service users. Most of the service users attend day services in line with their individual needs. The home uses local transport to access community activities. The home has established links with local professionals so that the service users specialist needs can be responded to. The fees range from £600 to £650. Copies of this report are available from the Commission Website. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection was undertaken as part of the annual inspection programme. We sought to confirm that the three areas for improvement identified at the last inspection had been addressed. Prior to the inspection the home had completed its annual quality assurance assessment. The annual quality assurance assessment provided us with information about the home and how it was seeking to provide the best outcomes for people. We also looked at any other information we had received about the home since the last inspection. This included any information regarding incidents that the home had told us about. The inspection took place over two days. We were assisted by Zahia Lahouasnia, MENCAP Area Manager and Paula Wilson the registered manager, with the inspection. An expert by experience accompanied us. The expert by experience had personal experience of the issues faced by people with a learning disability. The expert by experience spoke with people and observed how staff cared for them. At the end of the inspection the expert by experience gave us feedback on what they had found. The findings of the expert by experience are referred to the relevant outcome areas in this report. We spoke with two the people who live at the home, and three members of staff. We observed care practice and interaction between staff and people living at the home. We toured the building and examined a number of records relating to the care, health and safety and management of the home. At the end of the second day of the inspection feedback was given to the registered manager, and areas for improvement were discussed. We would like to thank the staff that assisted us by answering questions about the running of the home. We would also like to thank the people who live at the home who discussed their views of the service they receive. What the service does well: Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 6 The home provides consistently good outcomes for people. The statement of purpose clearly sets out the philosophy and objectives of the home. The home understands the importance of having sufficient information when choosing a care home. Admissions to the home are made on the basis of a detailed assessment. This ensures the best outcomes for people who live at the home. The home has continued to improve care plans so that they are more person centred. The home involves individuals in the planning of care that affects their lifestyle and quality of life. Risk assessments were found to cover all areas that affected the people’s daily life. Risks are managed positively to help people living at home to lead the life they want. The menu is prepared at a weekly meeting of people living at home. A variety of meals are provided that reflect the individual preferences of people who live at the home. Care plans outlined the support people require to maintain their independence when being supported with their personal care. Personal support is responsive to the varied individual needs and preferences of people who live at the home. People told the expert by experience that they “visited the doctor and when they are very poorly the doctor will come to the house.” People are supported to access the healthcare they need. We found that records for the administration of medication were complete. People’s medication had been reviewed regularly to ensure their continued well being. The complaints policy is available in a pictorial format. People who live at the home are supported to share their concerns. The home has an open culture that allows people to express the views and concerns in a safe and understanding environment. People who live at the home told us that they could challenge and raise concerns about the way they were treated. People living in the home feel safe and well supported by an organisation that has their protection and safety as a priority. Training records confirmed that all staff has all the statutory required training. All staff receive relevant training that is focused on delivering improved outcomes for people. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 7 A system is in place to monitor the quality of the service provided by the home. Ongoing quality assurance is carried out to make sure that the home provides improved outcomes for people. The registered manager makes sure that the safety risks to people living at the home and staff is identified. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff. 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. The summary of this inspection report can be made available in other formats on request. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose is an accurate description of the service provided. People’s needs are assessed prior to admission to the home to ensure they receive the care and support required. EVIDENCE: The statement of purpose clearly sets out the philosophy and objectives of the home. We found that the needs of the people case tracked were within a range of those specified in the statement of purpose. The statement of purpose also identified the skills and staffing resources that are available to meet the needs of people living at home. As is outlined in the following outcome areas these resources generally meet the needs of people living at the home. The statement of purpose positively promoted the rights of people living at the home to express their diversity. We discussed the issue of equalities and diversity with registered manager who demonstrated that she would respond positively to people’s diverse and varied needs. The registered manager had highlighting in the annual quality assurance assessment that the statement Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 10 purpose and service user guide will be made available in an audio format. The registered manager explained this would allow people to have easier access to this information. The home understands the importance of having sufficient information when choosing a care home. We case tracked three people who live at the home and found that there were assessments from the home and care management. The annual quality assurance assessment stated that, “Each resident has a detailed needs assessment which forms the basis of their support plans.” A person commented that the home was a “ good” place to live.” Initial assessments identified the needs of people living at the home. This included a history of their needs and any resulting behavioural management issues. The annual quality assurance assessment told us that the home trying to further develop the assessment process. The aim is to provide a more person centred assessment of people’s needs. People’s needs were identified prior to their admission to the home. Admissions to the home are made on the basis of a detailed assessment. This ensures the best outcomes for people who live at the home. There have been no new admissions since the last key inspection. We found that the needs of the people case tracked had been reviewed both by the home and by their social workers. Records showed that people had been consulted about the decisions made at their reviews. Peoples changing needs are planned for to ensure their well being. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 11 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): 679 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans provided detailed information on the needs of people living at home. People are supported to make decisions about their lives. Risks to service users are assessed to ensure their safety and independence. EVIDENCE: The home has continued to improve care plans so that they are more person centred. The annual quality assurance assessment stated, “ All residents have comprehensive personal care plans which identifies their individual needs.” The care plans of the three people case tracked were personalised and detailed how the individual’s needs would be met. The registered manager had noted in annual quality assurance assessment that more staff had been trained in person centred planning. Care plans were found to provide detailed Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 12 information on the support provided to meet the needs of people. Care plans also referred to the cultural needs of people. This included whether or not they wish to take part in religious activities. It also included how people were to be supported to express their sexuality. I spoke staff that understood the importance of supporting people to express their sexuality. All people living in the home had a key worker to make sure that the individual needs are met. People I spoke to told me that they felt staff understood their needs. A person said, “ Staff are nice and helpful.” I found that care plans had been developed with the involvement of people living at home. I observed that staff took time to understand people and do things in the way they had been asked. When people returned from the day centre they were offered a hot drink. The home involves individuals in the planning of care that affects their lifestyle and quality of life. Details of people’s behaviour that might challenge the service were identified in their risk assessments and care plans. Actions to address and manage these behaviours are outlined in detail. We spoke to the area manager who explained that medication used to help people manage their behaviour was reviewed regularly. MENCAP has a specialist working with staff at the home to further develop care plans in this area. The area manager told us that staff are looking at what might trigger certain behaviours and how this could be addressed. People had been consulted about how they wished to be assisted to manage their behaviour. Staff spoken to understood both the general principles, and specific needs of people living at the home with regards to how behaviour is managed. The expert by experienced observed that “we were advised not to meet a male resident as he sometimes gets quite distressed.” The registered manager explained that staff had been trained in how to deal with behaviour may be challenging. The registered manager told us further training in this area is being planned. Behaviour that may challenge the service is addressed sensitively to support and maintain people’s well being. Risk assessments were found to cover all areas that affected the people’s daily life. Risk assessments identified the specific risks facing people. These are reflected in care plans. Risk assessments had been reviewed. Any changes to the level of risk were addressed. Risks are managed positively to help people living at home to lead the life as they want. The registered manager explained that as part of responding to any incidents risk assessments would be reviewed. Where necessary changes to the risk assessments and care plans are put in place. We received shortly after the inspection a notification of an incident. A person had fallen. We spoke with the deputy manager who explained that the persons risk assessment had already been reviewed to ensure the persons continued safety. Staff were able to describe how they prevented risks to make sure that people were safe, and were supported to exercise control over how they live. Risks Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 13 relating to behavioural issues were identified and actions to lessen the level of risk were discussed in team meetings. I observed that staff engaged with people living at home in an appropriate adult way. A comprehensive risk assessment that is reviewed regularly is in place to ensure the safety and independence of people living at the home. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 14 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): 12 13 15 16 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to engage in a range of activities that meet their needs. People have community contacts and are supported to maintain personal relationships. People are supported to have a nutritious diet that reflects their personal choice. EVIDENCE: People said that they could choose from a range of activities. The registered person said in the annual quality assurance assessment, “The residents who wish to attend day centres are supported to do so.” We found that on the day of inspection three people were attending day centres. The people spoken to by the expert by experience said that they are able to spend on their own if they wish to. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 15 People told the expert by experience that they were not able to go out in the evening to clubs or the cinema as much as they liked. The registered manager had highlighted that two more staff are needed to provide sufficient cover for trips to activities outside the home. We discussed this with the registered manager, who explained that the need for increased staffing had affected provisions of activities. She was trying to address this issue by the use of bank staff. The files three people case tracked showed they had had some access to community based activities. The registered manager is working with the placing authority to agree an increase in the staffing level. The files of the three people case tracked showed that they are involved in domestic activities, such as cleaning their rooms. The expert by experience was concerned that people felt they could be more involved in doing domestic tasks. We discussed this with the registered manager who agreed to make sure people were supported to be fully involved domestic tasks around the home. The menu is prepared at a weekly meeting of people living at home. I saw minutes of these meetings that confirmed people’s suggestions for meals were recorded. People spoken to confirmed that they had been involved in preparing the menu. The expert my experience felt that the menu should be available in a picture format. This will help people to know what meals are available each day. This was discussed with the registered manager who agreed to make menu is available in a picture format. Menus need to be easy to understand so that people are able to make a positive choice about what they eat. The menu is varied and reflected the cultural and dietary needs of individuals. We observed that there were fresh vegetables and fruit available. The expert by experience noted that there was no fruit bowl available so that people living in the home could have a piece of fruit when they wished to. We discussed this with the registered manager who agreed to put this in place. We saw that meals were well presented and were provided in a relaxed and supportive environment. A variety of meals are provided that reflect the individual preferences of people who live at the home. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 16 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): 18 19 20 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People are supported with their personal care needs to maintain their independence. People are able to access the medical care they need. People are protected by safe procedures for handling medication. EVIDENCE: The annual quality assurance assessment highlighted that “details of how service users like personal support is in their support plans.” Care plans outlined the support people require to maintain their independence when being supported with their personal care. We spoke with people who explained that staff provided support and encouragement to maintain their personal hygiene. The expert by experience found that people could choose when they had a bath or shower with the support of staff. Male and female carers are Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 17 employed in the home to ensure that people have same gender care. Peoples preference to have same gender care is reflected in their care plans. We observed that staff from various cultural backgrounds were available to meet the needs of people. Staff were able to explain the personal support needs of people living at the home. Personal support is responsive to the varied individual needs and preferences of people who live at the home. Medical needs had been identified as part of the initial assessment and were referred to in care plans and risk assessments. We spoke with people living at the home who told me that staff supported them to follow a healthy diet. The annual quality assurance assessment stated, “all service users have annual health checks.” People told the expert by experience that they “visited the doctor and when they are very poorly the doctor will come to the house.” People confirmed that they had been supported by staff to attend hospital appointments. Daily notes recorded that people had access to the opticians, dentists and chiropodists. People are supported to access the healthcare they need. Peoples health needs are addressed to ensure their well being. The medication policy contained all the required information. We found that records for the administration of medication were complete. Records of medication received and returned were also complete. All medication was held securely. People’s medication had been reviewed regularly to ensure their continued well being. There is clear guidance on the use of medication as part of managing peoples challenging behaviour. This outlined when it was appropriate to use this medication. It clearly stated the types of behaviour that would indicate that it was appropriate to use medication. The annual quality assurance assessment highlighted that in the last 12 months the home had been working with one person lives at home to develop more positive responses to their behaviour that may be challenging. This involved working with a multidisciplinary team to review medication and develop appropriate strategies. We found that the person’s records gave a clear indication of when medication was to be used to assist with managing their behaviour. Medication is only used to manage peoples behaviour when it is clearly required to meet their needs. Daily notes showed that health professionals had been consulted to ensure that people were receiving the medicines they required. Training records and discussions with staff confirmed that since the last inspection they had received training on the safe administration of medicines. Advice was available for staff on the side effects of medication. Medication is administered by staff that are properly trained to ensure the safety of people living at home. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 18 Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 19 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): 22 23 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence, including a visit to this service. People can be confident that their complaints are listened to and acted upon. Adult protection procedures protect people from abuse EVIDENCE: The complaints policy explained how to make a complaint and how it would be dealt with. The complaints policy is available in a pictorial format. People who live at the home are supported to share their concerns. Copies of the complaints policy were available around the home for people to consult. The complaints procedure is available in a number of formats to help anyone living at home, or involved with, the service to complain or make suggestions for improvement. Staff explained that people are encouraged to discuss their views of the service at weekly meetings. The home has an open culture that allows people to express the views and concerns in a safe and understanding environment. Since the last inspection there has been one adult protection issue. The registered manager responded proactively and appropriately in addressing this. All the relevant professionals had been notified. The allegation concerned the security of money held on behalf of people living at the home. The registered manager had reviewed the procedure about the handling of people’s money. Staff we spoke to were clear on the measures to be taken to make sure that people’s money is held securely. The home understands the procedures for Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 20 safeguarding adults and will always attend meetings or provide information to external agencies. People who live at the home told us that they could challenge and raise concerns about the way they were treated. People who live at the home told the experts by experience that they felt “safe”. We observed the way that staff approach people. This was done appropriately and sensitively. There were policies on handling abuse and adult protection. Training records showed that staff had received training in adult protection. We spoke with staff and they demonstrated their understanding of adult protection issues. Training about dealing with physical and verbal aggression has been made available to staff. People living in the home feel safe and well supported by an organisation that has their protection and safety as a priority. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 21 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): 24 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live in the home are always provided with a safe and homely environment. The home is clean and hygienic. EVIDENCE: We walked around the home and found that the home was clean throughout. There were separate dining and sitting rooms that were comfortably furnished. People were able to choose where they wish to sit or spend time in their bedrooms. Discussions with the registered manager and the annual quality assurance assessment confirmed that the kitchen has been redecorated to Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 22 provide a more homely environment for people living at the home. It stated that, “there has been extensive redecoration over the last 12 months.” We found that the hallways, sitting room and main staircase have all been newly carpeted. People we spoke to said that they had been consulted about the choice of the carpet and its colour. A person who lives at home said that it was “very nice.” Maintenance records showed there were no outstanding repairs. The home provides a physical environment that is appropriate decorated and furnished in line with people’s wishes. The annual quality assurance assessment highlighted that the doors to the upstairs bathroom had been replaced with sliding doors. This had been done to ensure the safety of one person who lives at home who has epileptic seizures. Staff explained that this allowed them to provide effective support to the person without affecting their independence. The home provides a physical environment that is appropriate to the specific needs of people who live there. We observed that toilets and bathrooms had been adapted to ensure people could access them easily. The home’s environment is adapted to meet the specific needs of people. People spoken to were pleased with their bedrooms. They had chosen items of furniture for their rooms. People are encouraged to personalise their bedrooms. We observed that people’s bedrooms have been decorated and furnished in ways that reflected their personal preferences. The expert by experience spoke to one person who was concerned that the draw of her cupboard was broken. We found this to be the case. We discussed this with the registered manager who explained that a new cupboard would be purchased. It is recommended that a new cupboard be purchased. People need to have furniture that is safe and fit for purpose. Appropriate measures are in place to prevent cross infection. The expert by experience observed that the home was “clean and hygienic.” The home has detailed policies on the prevention of cross infection. The annual quality assurance assessment stated that staff had training on infection control. New staff had been booked on infection control training. We found that training records confirm this. Staff spoken to understood how to work to minimise the possibility of cross infection. Staff confirmed that they had access to disposable gloves and aprons. Liquid soap and paper towels were available throughout the home. A proactive infection control policy makes sure that the risk of infection for people is minimised. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 23 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): 32 34 35 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Sufficient staff with the necessary skills are available to meet the needs of people. A training plan is in place that identifies all areas of training needed to meet the needs of people living at home. People are protected by the home’s recruitment procedures. EVIDENCE: I found that the rota showed that a consistent staffing level was maintained. The rota also showed that staff were on duty to provide escorts to appointments and support with activities when this was necessary. The expert by experience highlighted that people felt they could not get out to local activities due to lack of staffing. Staff told us that due to the need for two staff to escort people it was not always possible to engage in activities in the local community. People’s records show that they had been on visits to local shops and the cinema. The registered and area managers explained that they were in negotiation with the placing authority to obtain increased funding for the Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 24 necessary increase in staff numbers. We saw a report that had been sent to Enfield Social Services outlining the case for increased funding for staffing. The registered manager explained that she is using bank staff on a regular basis so that people are able to take part in community based activities. The home makes sure that sufficient staff is made available to meet the needs of people. The registered person provided us with a copy of the current training plan. This identified future training needs and how these would be addressed. Training records confirmed that all staff has all the statutory required training. All staff receive relevant training that is focused on delivering improved outcomes for people The annual quality assurance assessment showed that two new staff had started working at the home since the last inspection. Records were available to confirm that these two staff had been on the necessary induction training. Staff commented that the registered manager positively encouraged them to go on training to develop their skills. Training records showed that 50 of staff has either level 2 or 3 in the National Vocational Qualification in care. The home ensures that all staff receives relevant training that is focused on delivery of improved outcomes for people using the service. We looked at three staff files and found they contained all the necessary documentation relating to their recruitment and appointment. Staff go through a detailed interview process. We found there were notes in staff files to confirm this. People can be confident that they are protected by the home’s recruitment procedures. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 25 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): 37 39 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence, including a visit to this service. Effective management systems are in place to make sure that people’s will being and safety is promoted. People’s views of the service are sought and used as the basis for improvement. People who live at home and staff’s health and safety is always promoted and safeguarded. EVIDENCE: Staff and people told us that the registered manager is supportive and approachable. Training records showed that the registered manager has the skills and experience to manage the home to meet the needs of people. Records showed that staff receive regular supervision from the registered Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 26 manager. Staff meetings were held to discuss practice issues in the home. The registered manager demonstrates a clear understanding of people’s needs and uses the available resources to ensure their well being. A system is in place to monitor the quality of the service provided by the home. The registered manager explained that she carries out quality monitoring on a regular basis. An action plan is developed to address any areas for improvement that are identified. We were able to see these action plans and confirmed that issues raised were addressed. Ideas for improvement are sought. The annual quality assurance assessment was completed by the home. It showed that the registered manager knows what the home does well. It also identified areas where further improvement could be made. Ongoing quality assurance is carried out to make sure that the home provides improved outcomes for people. People are consulted about how the home is run. Minutes were seen of meetings held with people who live at the home to discuss the quality of the service provided. People said that they are encouraged to discuss their views of the service in weekly meetings. Action to improve the service had been agreed with people who live at the home. Theres a strong emphasis on being open and transparent in all areas of the running of the home. The registered manager makes sure that the safety risks to people living at the home and staff is identified. Measures are put in place to provide a safe living and working environment. Records showed that fire equipment was tested regularly and maintained. Fire Drills were taking place. The fire risk assessment provides details of potential risks of fire. All health and safety policies were available. Certificates for gas and electrical testing were in date. COSHH guidance is in place and chemicals were stored safely. All training on health and safety topics was complete. People living at the home are aware of safety arrangements and have confidence in the safe working practices of staff. Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 27 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 3 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 4 23 4 ENVIRONMENT Standard No Score 24 3 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 x 3 X 3 X x 3 x Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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 YA17 Good Practice Recommendations The registered persons should make sure the menu is available in a picture format. Menus need to be easy to understand so that people are able to make a positive choice about what they eat. The registered persons should make sure that a new cupboard be purchased for the person’s bedroom identified at the inspection. People need to have furniture that is safe and fit for purpose. 2 YA24 Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 29 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 Mencap (Chasewood Avenue) DS0000010572.V356009.R01.S.doc Version 5.2 Page 30 - 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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