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Inspection on 02/03/06 for 22-24 St Hughs Avenue

Also see our care home review for 22-24 St Hughs Avenue for more information

This inspection was carried out on 2nd March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Medication policies and procedures are in place to provide staff with appropriate guidance on handling medicines. Medication is generally well managed at St Hugh`s Avenue, ensuring that service users receive the medicines they require. There are effective complaints procedures to listen to and respond to matters raised by service users or their representatives. Adult protection and whistle blowing procedures are in place to ensure that service users are protected from the risk of harm and poor practice challenged. Service users are cared for by qualified and competent staff, ensuring that care needs are adequately met.

What has improved since the last inspection?

Rotas now contain the surname of staff and precise hours to be worked. The approach of one member of staff has been discussed in supervision to promote respect, privacy and dignity.

What the care home could do better:

The provider needs to write to the Commission regarding proposals to close the home in the future, in order that the necessity to fit sinks in bedrooms can be evaluated, subject to the timescale of any proposals. The date of opening creams should be added, to ensure that any such medicines are destroyed after 28 days of opening.

CARE HOME ADULTS 18-65 St Hughs Avenue (22/24) Micklefield High Wycombe Bucks HP13 7JD Lead Inspector Chris Schwarz Announced Inspection 2nd March 2006 10:00 St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Hughs Avenue (22/24) Address Micklefield High Wycombe Bucks HP13 7JD 01494 444507 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) The Fremantle Trust Mrs Pamela Wheeler Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th December 2005 Brief Description of the Service: 22-24 St Hugh’s Avenue is located in a residential area, Micklefield, east of High Wycombe town centre. It is registered to provide accommodation for up to six adults with learning disabilities and was full at the time of this inspection. The home is close to local shops and transport into nearby towns and is owned and staffed by The Fremantle Trust. All bedrooms are single and the home has been decorated and arranged to reflect a family environment. Service users have a cat called Bunty. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This short announced visit, lasting just under two hours, took place to supplement the unannounced inspection in December 2005. The registered manager and her line manager were present to discuss the remaining key National Minimum Standards for younger adults and to follow up on some matters raised during the unannounced visit. One recommendation has been made on this occasion. The other recommendation (number 1) and one requirement (still in timescale) will be looked at as part of the next inspection when these standards are routinely reassessed by the inspector. Overall, the home was providing good standards of care to people with learning disabilities. What the service does well: What has improved since the last inspection? Rotas now contain the surname of staff and precise hours to be worked. The approach of one member of staff has been discussed in supervision to promote respect, privacy and dignity. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 6 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. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 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 St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 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): EVIDENCE: None of the standards in this section were assessed on this occasion. There had not been any new admissions since the last inspection in December 2005. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 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): EVIDENCE: None of the standards in this section were assessed on this occasion. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 10 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): EVIDENCE: None of the standards in this section were assessed on this occasion. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The management of service users’ medication is generally well handled, ensuring that people receive the medicines they require to keep them healthy and well. EVIDENCE: Medication procedures are in place at the home and cover all required areas of practice, to ensure that safe systems are in place. The cabinet was secure and administration sheets in good order, with a photograph of each service user and their general practitioner details listed on the inside of the medication folder. The home continues to use a monitored dose system of medication administration, which works well. The only matter that needed attention was ensuring that the date of opening is added to eye cream prescribed for one service user, to ensure that it is disposed of after the recommended 28 days. A recommendation is made to add dates of opening to any creams in use at the home. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 There are effective complaints procedures in place, to ensure that matters raised by service users or their representatives are listened to and responded to. Adult protection and whistle blowing procedures are in place to ensure that service users are protected from harm and poor practice challenged. EVIDENCE: The home has a complaints procedure in place, Fremantle Feedback, and a log is maintained of any issues raised by service users or their representatives. Most of the people living at the home would be able to articulate any concerns they have about quality of care. The complaints log was examined and only compliments had been received over the course of the last year. There are adult protection procedures in place to respond to any allegations or suspicions of poor or abusive practices. The home is awaiting revised local authority procedures to be produced, in order to update its copy of the local multi-agency guidelines. The manager will shortly be attending a train the trainers course on Protection of Vulnerable Adults and subsequently cascading this to the staff team. The manager and service manager said there had not been any adult protection concerns over the course of the last year and the Commission is not aware of any. As a good practice, the manager had involved the community nurse to ensure that one of the service user’s was able to consent to a personal relationship and the subsequent precautions. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The only environmental matter discussed on this occasion was the provision of sinks in bedrooms. At the last inspection, a requirement was made for sinks to be fitted in the rooms that did not have one already in place. The service manager was able to contribute to discussions on this occasion and said that there are plans to leave the existing property as part of an overall resettlement project. The requirement has been removed from the report pending written confirmation from the provider regarding the plans for St Hugh’s Avenue and the expected timescale, in order to assess whether the provision of sinks should be pursued or not. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 The people living at St Hugh’s Avenue are supported by a competent and qualified staff team, ensuring that needs are adequately met. EVIDENCE: The home had one thirty hour support worker vacancy at the time of this visit. No agency staff were needed to cover the rota and an experienced, permanent group of staff was providing care to service users. There was good progress in obtaining National Vocational Qualifications, with all but two people having achieved at least level 2 in care. None of the staff team was under 21 years of age. Rotas had been revised as recommended to include the surnames of staff and precise hours of working were noted. No new staff had been taken on in the course of the last year therefore recruitment was not assessed on this occasion. With the current support worker post vacant, there is scope to assess the standard at the next inspection of the home. By way of follow up to a requirement made at the last inspection, the approach of one member of staff has been discussed in supervision to promote respect, privacy and dignity. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 15 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): EVIDENCE: The only matter discussed under these standards was fire drills. The manager pointed out that at the last inspection a requirement had been made to carry out fire drills every six months, in response to a gap on the record sheet. A second record sheet was shown and this provided evidence of a false alarm being used for fire evacuation purposes during the period of the gap, and was recorded as an evacuation. This second record has now been taken out of use in order that just one record is maintained. The home had therefore been fulfilling responsibilities to conduct fire drills at the appropriate interval and apologies are given for any inconvenience caused. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 x x x x x x x x x x St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 17 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 YA35 Regulation 18(1)c(1) Requirement All mandatory training is to be brought up-to-date, where necessary, and for the training records to be maintained accurately, including courses attended by any relief staff working at the home. Timescale for action 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA20 Good Practice Recommendations Records of medical appointments are to be added to each person’s individual care plan folder. The date of opening is to be added to creams prescribed for service users. St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 St Hughs Avenue (22/24) DS0000023046.V285427.R01.S.doc Version 5.1 Page 19 - 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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