Inspection on 19/01/10 for 89 Pavenhill

This is the latest available inspection report for this service, carried out on 19th January 2010.

CQC found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

89 Pavenhill 16/03/06

89 Pavenhill 04/10/05

89 Pavenhill 22/03/05

89 Pavenhill 24/11/04

89 Pavenhill 19/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: 89 Pavenhill 89 Pavenhill Purton Wiltshire SN5 4DA     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Pauline Lintern     Date: 1 9 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 31 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 31 Information about the care home Name of care home: Address: 89 Pavenhill 89 Pavenhill Purton Wiltshire SN5 4DA 01793771373 01793771373 pavenhillmanager@whct.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: White Horse Care Trust care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who may be accommodated is 3. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home 89, Pavenhill is one of 14 care homes that are run by The White Horse Care Trust. The home offers accommodation and personal care to two people with learning disabilities. The building is a detached bungalow in Purton. There are two bedrooms, a lounge with dining area and a garden to the front and rear of the property. There is a shower room with toilet and another toilet is available close to the kitchen area. The service users receive personal care and support throughout the day from a permanent staff team. There is at least one member of staff on duty throughout the day, one in the evening and one sleeping in. The philosophy of care emphasises the importance of an ordinary, domestic type home environment and the involvement of people with a learning disability within the wider community. Each service user is offered a range of daytime and leisure activities and is well known in the local community. Care Homes for Adults (18-65 years) Page 4 of 31 3 Over 65 0 Brief description of the care home Care Homes for Adults (18-65 years) Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The unannounced key inspection took place on 19/01/2010. At the time of our visit one person had just returned to the home after visiting the doctor with a member of staff. The other person who lives at the home had already left to attend day services. Throughout the day we were able to talk to the person who was at the home and the member of staff on duty. The registered manager of the home is Ms Karen Brogan and on this occasion we were unable to meet with her during our visit. However the following day we were able to feed back electronically and also spend time discussing our visit with the deputy manager on the telephone. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was completed and its contents used as part of the inspection process and report writing, as was the collation of survey results from both service users and staff. We received two completed surveys from the people using the service and three from members of staff. Care Homes for Adults (18-65 years) Page 6 of 31 Comments from our surveys are included within this report. We reviewed the information that we had received about the home since the last inspection. We looked around the home and read a number of records, including care plans, risk assessments, health and safety procedures, quality assurance and staff training records. Any information we could not obtain on the day of our visit, was forwarded to us after the inspection. The judgements contained in this report have been made from all the evidence gathered during the inspection; including the visit to the service and takes into account the views and experiences of people using the service. Care Homes for Adults (18-65 years) Page 7 of 31 What the care home does well: What has improved since the last inspection? The home continues to provide a high quality service to the people living there. Care Homes for Adults (18-65 years) Page 8 of 31 Members of staff continue to support the people using the service to enjoy an active, full and valued lifestyle. Staff members have further developed a person centred approach within the home. Some improvements have been made to the building such as new doors and a newly fitted patio area. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. People are provided with information to enable them to decide if the home is right for them. An established referral and care assessment format is used to by the home to assess peoples needs to ascertain if they can be met by the service. Evidence: The home has an updated statement of purpose and a service user guide, which provides information about the service and how it is managed. All interested parties have access to this information prior to deciding if they wish to move in. Since our last visit to the home there has been one new admission. Records show that the person had the opportunity to visit the home and have overnight stays prior to making a decision about coming to Pavenhill. Consideration had been given to the needs and choices of the person already living at the home. Their views were Care Homes for Adults (18-65 years) Page 11 of 31 Evidence: considered throughout the process. We asked how the existing person was adapting to the new person and they told us that its ok, they are nice. Records show that since moving into the home the most recent resident appears to have settled in well and is enjoying the less noisy environment, which they had previously experienced. Staff confirmed that some initial behaviours experienced are no longer displayed, which indicates that the person is happy at the home. Each person living at the home has a written contract and a service user guide, which is supported with pictures. They also have a copy of the complaints procedure and a copy of their terms and conditions. Care Homes for Adults (18-65 years) Page 12 of 31 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. Each person living at the home has a care plan, which is kept under review and reflects their assessed needs. People using the service are supported to exercise choice and control in all aspects of their daily lives. Where potential risks emerge strategies are put in place to minimise them. Evidence: As part of the inspection process we looked at each persons care plan. We found the plans reflected assessed needs and documented any changes that may have taken place. We saw that the service have considered peoples diversity and have responded accordingly to ensure that their needs continue to be met. For example due to one Care Homes for Adults (18-65 years) Page 13 of 31 Evidence: persons age and increased frailty, they sometimes choose to let the staff members take on some of the household tasks that they previously enjoyed doing. Staff members told us that X will sometimes ask staff if it is alright for them to wash up or carry out other tasks they used to do regularly. She added that staff members will ensure they are safe and observe the task being completed without being too intrusive. The home have further developed working with a person centred approach. Records show that each person has a person centred plan, which details a persons skills, safety, choices, areas they may need support with and areas the person is able to do independently. We saw that one person had stated that their perfect weekend would be to stay in bed all day. Another person has identified their circle of support. This is a list of people that are important to the individual and who are involved in their life. We noted that one persons circle of support was so full of names there was little room to add any more. People using the service attend their review meetings if they choose to do so. We saw that a representative from day services attended along with friends of the person living at the home. Records chart progress being made towards a person reaching their goals and aspirations. One goal was to the cinema more often. The progress report stated that this could on occasions be difficult due to day services commitments. Another goal was to travel on the bus more often and maybe on a train. Records are made of when this has been achieved. The home has a key worker system in place and often it is the key worker who will take responsibility for supporting the person to reach their goals. As mentioned in the summary of this report this is a home that continues to excel at putting people at the centre of the service. There appears to be a good balance between giving gentle encouragement, offering choice and respecting decisions for a personal choose. Throughout our visit we continually observed X making decisions about their life. X told us in their survey they look after me well and listen to what I ask or tell them. One staff member told us that X will often remind staff that I am the boss. We looked at individual risk assessments and found that they are kept under review. We noted that when an incident had taken place this had been recorded appropriately on the incident and accident form, action had been taken to reduce the risk of the Care Homes for Adults (18-65 years) Page 14 of 31 Evidence: incident happening again and health professionals had been consulted and a behavioural management plan was in place. One member of staff told us that they had not experienced a repeat of the incident since. There is a risk assessment in place for each person to ensure safe systems are in place. Care Homes for Adults (18-65 years) Page 15 of 31 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. People living at the home are supported to take an active part in the local community. Members of staff continually explore new and meaningful activities for the people they support. Friendships and family involvement is paramount at Pavenhill. Menus are developed with full involvement of the people using the service. Evidence: Staff members report that one person living at the home prefers not to participate in too many social events. However, since being at Pavenhill they have increased their daily trips to the day centre. Staff told us that they now help the co-ordinator to lay the glasses on the table at the centre, although they prefer to sit on the sidelines and Care Homes for Adults (18-65 years) Page 16 of 31 Evidence: watch others completing their activities. Staff respect this decision and do not place any pressure on the person. Staff told us that the person enjoys spending time knitting, watching the television and looking at books, especially cookery books. One person told us how they enjoyed attending the day services and how they regularly win at Bingo. They told us about a friend (worker) at the day centre who had a motorbike and a sports car. They showed us a photograph of them sat on the motorbike at the centre. Daily notes and records demonstrate that the people living at Pavenhill are regularly invited to local events run by different organisations. One staff member told us about a 50s event held at the day centre. They explained how they had purchased a blond pony tailed wig, leather type jacket and short skirt for X to wear. They confirmed that X had won the best teddy girl competition as a result. Staff reported that following the event X requested having her hair dyed blonde as she liked it so much. Staff arranged for an appointment at the hairdressers for X to have a temporary colour applied. We saw in care plans that staff had asked both people living at the home where they would like to go on holiday this year. One person said clearly they would prefer not to go away and the other person has booked to go to Weston Super Mare in May. One person living at Pavenhill has lived in the area for a great number of years and therefore is known by most of the villagers and their families. Due to this the home is always filled with visitors and friends popping in to see if everyone is ok. One staff member told us X will invite everyone in for a cup of tea, when she meets them in the village. As they do year Pavenhill took part in the Purton carnival, decorating the house and front windows. During our visit we saw X making her rugs, which she continues to enjoy. She told us that she had nearly finished this one and would then start on another. One member of staff told us that one rug X made had a cross on it and X gave it to the church where the vicar blessed it for them. Within our surveys X told us I want to carry on making my rugs. People living at the home have regular visits from the pastoral carer, who will deliver Holy Communion at the home. Occasionally people will be supported to attend church for special services. Care Homes for Adults (18-65 years) Page 17 of 31 Evidence: Staff told us about supporting X to write a feature in the local parish magazine about their life story. This is now displayed at the local museum. On Thursdays a member of staff supports people to choose the menu for the following week. She reported that they tend to like the same familiar food and do not like to deviate from this too much. They explained that although they compile a menu, this is often changed on the day, if people request alternatives. We asked if the people at the home carried out the food shopping. We were told Oh yes, there is no way X would allow us to choose the food by ourselves. Care Homes for Adults (18-65 years) Page 18 of 31 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. Personal support is given in a way, which people prefer. Advice and guidance is sought from healthcare professionals when needed. The arrangements for managing medicines are good. Evidence: People are consulted on the amount of support they require and this is recorded in their individual support plan. We noted in one persons support plan it states under privacy and dignity, X requires staff support to maintain their dignity at all times, such as with clothing or behaviours, respect and choice. Staff to support X by giving her enough one to one time to reduce anxiety and raise her confidence to make decisions. One plan records when dressing X requires support with certain items to ensure correct fit and that it is being worn correctly. Care Homes for Adults (18-65 years) Page 19 of 31 Evidence: One person showed us their bedroom and told us that they always kept it tidy and made their own bed. There was good evidence in the daily records that any concerns about peoples medical conditions were immediately referred to the relevant health care professional. On the day of our visit one person had just returned from the doctors surgery. They told us that they had been prescribed some tablets to help their chest. Staff confirmed that they always acted promptly if X is unwell as due to their age they are particularly vulnerable. They added that the home receive very good support from local healthcare services. They told us that two ex practice nurses, continue to visit the home with their children to see the people who live there. Each person living at the home has a health action plan in place. There is also a document called my health in hospital for each person. This provides the reader with important information about each individual, which could make a difference to their visit/stay in hospital. Weights are monitored and recorded and people have the opportunity to have flu vaccinations during the winter months. As part of the inspection process we looked at the arrangements for managing medicines. We found that records were well kept, with no gaps and medicines are stored appropriately. Stock is regularly checked and all medicines are signed in and out of the home by staff members. Before staff are able to administer medicines they are appropriately trained until; they are deemed competent. Care Homes for Adults (18-65 years) Page 20 of 31 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. A clear and effective complaints procedure is in place. The service has policies and procedures in place for the Safeguarding of Vulnerable Adults. Evidence: Within the statement of purpose and service user guide people can find information on how to make a complaint or raise a concern. People are provided with a pre addressed postcard to the Trusts Chief Executive, if they wish to use it. It is clear from meeting X that any concerns or complaints they may have would be readily shared with staff members as this is the ethos of the home. Staff told us how the other person at the home will communicate to staff if they are not happy or do not wish to do something. This service remains one that is rarely complained about, however any issues raised would be listened to and taken seriously. The deputy manager explained to us that sometimes X finds it difficult to accept and understand why so many people visit the home and ask her so many questions about whether she is happy with things. The member of staff told us that X will often refer to them as being nosey parkers. This reiterates how this service is considered by the people living there as a real home and is run as such. Care Homes for Adults (18-65 years) Page 21 of 31 Evidence: There are established policies and procedures in place with regard to the safeguarding of vulnerable people. Staff confirmed that they have seen a copy of the local protocols (No Secrets) for reporting any suspected abuse taking place. We saw that staff attend refresher training in abuse awareness annually. Within the AQAA, it states under what we could do better, ensure that all staff knows their responsibilities within the whistle blowing policy. As part of the inspection process we looked at the arrangements for holding monies on behalf of the people using the service. We looked at money transaction records and checked balances against cash held. We found this to be in order. Care Homes for Adults (18-65 years) Page 22 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. People living at the service are provided with a safe, clean and homely environment. Evidence: The home is a bungalow situated in the centre of the village of Purton. It is in keeping with other properties in the area and is in walking distance from local shops and amenities. On our arrival we found the home to be clean and tidy, with no unpleasant odours. The home is decorated and furnished appropriately to meet the needs of the people who live there. A feature of the service is the small family style service that is provided. All areas of the home were clean and hygienic. Surfaces, walls and floors were found to be spotless. The home appears to be well maintained. Staff told us that a new patio area had been built last year. As the home never misses the opportunity to hold a social event, a patio opening party took place. Staff reported that X and the Trusts chief executive cut the ribbon to declare the patio open. Care Homes for Adults (18-65 years) Page 23 of 31 Evidence: Throughout the Trust homes staff take on designated responsibility for certain health and safety areas within each home. The staff member on duty at the time of our visit explained that they were responsible for the management of toxic materials (COSHH). Another member of staff is responsible for infection control. They complete regular audits and attend training, which they share with other members of staff during team meetings. We saw that the home has a good supply of protective clothing such as aprons and gloves. Care Homes for Adults (18-65 years) Page 24 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. Staff demonstrate overall competency and appear to be sufficient in numbers, properly recruited, inducted, supervised and trained. Evidence: The home is run with one member of staff on duty during the day and at night, when they carry out sleeping in duty. We asked the member of staff on duty if they felt that this was sufficient to meet the needs of the people being support. They confirmed that this was sufficient numbers and did not prevent any activities from taking place. Due to the location of some staff members homes, staff are always available at short notice to support the staff on duty if they are needed. On the day of our visit one member of staff had popped in to offer support while one person attended the doctors. Due to the ethos of the home, many staff members wish to put in the extra hours and are happy to go the extra mile for the people they care for, which is commendable. Since the last inspection two members of staff have been recruited on a permanent Care Homes for Adults (18-65 years) Page 25 of 31 Evidence: part time basis. Both have previously worked for the Trust in the capacity of bank workers, therefore they have a good knowledge of the needs of the people living at the home. At the time of our visit we were unable to access recruitment files, however we were provided with the required information the following day. The Trust carries out checks on all new members of staff to ensure that they are suitable to work with vulnerable people. Two references are sought, along with proof of identity and a medical declaration. The home has an established induction programme for all new members of staff. Within the AQAA it states under what we do well, we provide a good induction to the home and the Trust. The Trust has a comprehensive training programme and a training co-ordinator based at the head office. This ensures that all staff attends refresher training when required and are kept up to date with any changes. Mandatory training takes place which includes, fire awareness, health and safety, manual handling, basic food hygiene, first aid and abuse awareness. Within the AQAA it states that over 75 percent of the staff at Pavenhill hold a National Vocational Qualification level 2 or above. Staff members told us that they are regularly supervised and supported by their seniors. Team meeting minutes were sampled and they showed that the people who live in the home also attend he meetings if they wish to do so. Discussions take place around health and safety, training, running of the home and care plans. Care Homes for Adults (18-65 years) Page 26 of 31 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. This judgement has been made using available evidence including a visit to the service. People benefit from living in a home which is well run and their views are listened to. Peoples health, safety and welfare is promoted and protected by the health and safety measures Evidence: Mrs Karen Brogan is the registered manager of Pavenhill. She has over 33 years experience of working with people with a learning disability. She holds her Registered Managers Award and is an NVQ assessor. Mrs Brogan is not permanently based at Pavenhill but pays regular visits to the home when she will stay for lunch and is available to meet with the staff and the people they support. The deputy manager undertakes the day to day management of the home and has worked at the home for many years. Care Homes for Adults (18-65 years) Page 27 of 31 Evidence: As mentioned throughout this report, this is a home where staff encourages and support individuals to feel confident that this is their home, with staff being there to support them when needed. The Trust completes various management audits such as, monthly management audits, health and safety and finance audits to ensure that quality is maintained. In addition to this annual health and safety audits are completed by the Trust. The staff told us that they had achieved 100 percent at their last annual health and safety audit. Annual satisfaction surveys are sent out to all interested parties including, staff, people using the service and their next of kin. Results of the surveys are available. The results of the surveys contribute towards the homes development plan. Residents have the opportunity to attend regular residents days held by the Trust. The last meeting was held on 15/10/09 at Legg House in Wroughton. A nurse from Great Western hospital gave a talk and the community nurse spoke about health action plans. Within the AQAA it states that they are planning to have equality and diversity as the main subject for the next residents day. Health and safety policies and procedures are in place to ensure the well being of both staff and the people living at the home. Regular checks are carried out by staff members such as water temperatures, Legionella, fire equipment and emergency lighting. All radiators are covered to ensure that people do not scald themselves. Environmental risk assessments are completed and kept under review. Small electrical appliances were last checked on 18/11/09. The home recently received a visit from the Fire Officer, who completed an inspection of their systems for the management of fire protection. This resulted in some requirements being set, including an updated evacuation plan and risk assessment. We saw that the evacuation plan has been developed and tried in practice to ensure it was workable. This has yet to be checked and agreed by Mrs Brogan. Care Homes for Adults (18-65 years) Page 28 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 29 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 30 of 31 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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