Inspection on 04/08/06 for 22-24 St Hughs Avenue

This inspection was carried out on 4th August 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 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

22-24 St Hughs Avenue 31/07/08

22-24 St Hughs Avenue 02/03/06

22-24 St Hughs Avenue 11/12/05

22-24 St Hughs Avenue 01/02/05

22-24 St Hughs Avenue 29/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 St Hughs Avenue (22/24) Micklefield High Wycombe Bucks HP13 7JD Lead Inspector Mike Murphy Unannounced Inspection 4th August 2006 10:30 St Hughs Avenue (22/24) DS0000023046.V300794.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 St Hughs Avenue (22/24) DS0000023046.V300794.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. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 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) admin@fremantletrust.org 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.V300794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 2006 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. The average weekly fee at the time of this inspection was £567.40. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector over two visits in August 2006. The methodology included conversations with service users, with the mother of one service user who visited on the second morning of the inspection, and with the registered manager and staff. The inspection also included examination of records, a walk around the home and gardens, consideration of information submitted in advance of the inspection by the manager, and consideration of comments submitted by relatives and health and social care professionals. The inspection finds that this home provides a very good service to service users and their families. The service has a strong focus on the needs of service users. Its approach to assessing and meeting needs are good. Care plans, in the form of Person Centred Plans (PCPs), are detailed and drawn up with the involvement of the service user. The inclusion of scanned digital photographs and of personal photographs of past events is a positive innovation. Service users participate in a range of educational, social and leisure activities. The home maintain good links with local healthcare and social care agencies. The service is well managed and has an experienced team of staff. Staff benefit from the training policy and programmes of the Fremantle Trust. The service is due to be relocated to new accommodation 2007. Some service users will go to supported living accommodation at that time. Consultation meetings have been held with service users and their families and further meetings are planned. What the service does well: The small size of this service enables staff to support service users to be as independent as possible. Service users’ in participate in a varied range of social, educational and leisure activities. A homely, safe and comfortable environment has been created, providing pleasant surroundings for service users. Bedrooms are personalised and individual. The home is clean and hygienic, safeguarding against the risk of infection. Service users medicines are stored in individual locked cupboards in each bedroom. The standard of Person Centred Plans (PCPs) is very good. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 6 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. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are thoroughly assessed by experienced staff and involve other agencies as required. The assessment forms a sound basis for the formulation of a care plan to meet the service users needs. EVIDENCE: The home has received one admission since the start of the year. Referrals are made by Social Services care managers. Prospective service users and their families are provided with information on the home which allows them to consider whether it likely to be able to meet their needs. As the referral progresses the care manager provides the registered manager with relevant information on the prospective service user. A series of introductory visits are arranged which include tea with other service users and a weekend stay. At each stage, all parties, the prospective service user, the care manager and the registered manager, assess whether the home is likely to be able to meet the persons needs. An equally important consideration is whether the prospective service user and current service users are likely to get on together. The process extends over many weeks. If it goes well then a place is offered and, if accepted, a trial admission of a month or so is arranged which is followed by a further ‘settling in’ period. The home then develops a care plan with the service user which is aimed at ensuring that the home is able to meet the person’s needs. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 9 The home liaises with other services in the community as required when organising a package of care and support. Service users are informed of contact details of the ‘People’s Voices’ advocacy service. The home does not offer an emergency admission service. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user Person Centred Plans (PCPs) (care plans) are based on a thorough assessment of needs, are detailed, well written and support the provision of care appropriate to individual needs. Service users are supported in making decisions which maintains skills, encourages involvement in the life of the home and helps to maintain independence consistent with individual ability and needs. EVIDENCE: The care plans of three service users were examined. One of the senior care workers has a lead responsibility for developing ‘Person Centred Planning’. Care plans comprise the (PCP) and a daily diary. Three care plans were examined. The documents include a very good history, an excellent ‘map’ of people who are significant to the service user, a list of the individual’s positive qualities, pictures of important objects and activities, daily routine, matters important to staying healthy, things important to an ‘ideal home’, photographs of family and past events, a list of dislikes, detailed summaries of care plan reviews, reports from college, medical notes, and correspondence. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 11 Care plans were well organised, relevant and up to date. The daily diary is used to record day to day events, morning and evening. A diary on the office wall lists the regular activities attended by service users over the course of the week. The ethos of the home is for staff to work in partnership with each service user, encouraging and supporting them to make decisions and, as far as practicable, have influence over their lives. The extent to which individual service users’ can do so varies. Processes for conducting risk assessments are in place and there is a policy on unexplained absence ‘Missing Residents’. Arrangements for managing confidential information are satisfactory. The home is required to conform to The Fremantle Trust policy on this matter. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in attending a range of social, leisure and educational activities in the area. This helps to maintain independence and to ensure that activities meet the varying needs and interests of service users. Service users are involved in planning menus, shopping, food preparation, cooking and light household tasks. This help to maintain and develop service users skills in such everyday tasks EVIDENCE: The range of activities which service users participate in are listed in the weekly diary which is on the wall in the office and in individual PCPs. Service users also carry out some domestic tasks, some have time with their families, and all have a holiday or short break. Staff provide support and guidance as required. Each service user has one ‘at home’ day each week during which they attend to their own laundry and other domestic tasks, do their own St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 13 shopping, may have lunch out and pursue other interests. Staff provide support as needed. Staff and residents include a mix of ethnic backgrounds. The home had a positive atmosphere throughout this inspection. Staff and residents interacted well together and staff provided support and direction as required. Some service users attend college and attend sessions in numeracy, literacy, sport, beauty, and ‘well women’s groups. Other activities include gardening, day centres, social activities at a local Salvation Army centre, the Gateway club and activities organised by the Fremantle Trust in different homes which include garden parties. A garden party was planned for the end of August. Service users have had holidays in Croyde Bay in June and some are due to go to Hayling Island in October. A recent day out included a trip to Hastings. The home is about a mile or so from High Wycombe town centre and service users may make use of facilities such as the shopping centre, cinema (located on the edge of the town), swimming pool, lunch in one of the pubs, and occasionally, particularly around Christmas, at The Swan theatre in the centre of town. Service users make frequent use of the shop at a nearby garage. Staffing can be adjusted to support service users attending activities away from the home. The home is comprised of two semi-detached houses and is similar to other houses in the neighbourhood. Staff report that the home maintains good relations with neighbours. It is equipped with TV, radio and a music system and service users may have their own entertainment systems in their own rooms. Five of six service users maintain contact with their families. The daily routine in the home is determined to a large extent by the commitment of service users to college and other activities outside of the home. Staff respect service users right to privacy. Service users have unrestricted access to communal areas and the garden. A relative of a service user described it as a good home, safe, happy and cheerful. Meals are planned in consultation with service users. The manager and two of the care workers have attended a course on nutrition. Breakfast usually consists of cereals, toast, fruit juice and tea or coffee. Lunch is usually a packed meal of sandwiches, fruit and yoghurt. The evening meal is the main meal of the day and is served around 6:00 pm. The menu for the last week of July 2006 included: steak & mushroom pie and vegetables, sausage casserole, fish pie on Friday, and roast pork with vegetables on Sunday. Desserts are usually fruit, yoghurt or ice cream. Fluids are available as needed. It was said that tea is always available, as is fruit juice and cold water. Service users are St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 14 weighed monthly although this frequency has not always been maintained over the past year. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 & 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is provided in a form and pace appropriate to the needs of individual service users and involves healthcare professionals and other services as required. This ensures that service user’s healthcare needs are met. The storing of individual medication in service users own rooms helps to engage the service user in the administration of their medicines and reduces or eliminates institutionalised routines. EVIDENCE: Service users’ preferences are recorded in their PCP. Service users are supported in pursuing their own interests within the broader framework of daytime commitments, meals, the needs of other service users and the availability of staff. There seems to be a good level of flexibility within the home and service users choose their own hairstyle, clothes etc. Specialist health services can be accessed through the residents GP or the Learning Disability Community Nurses can be contacted direct. All service users are registered with a GP. Service users have access to an NHS dentist, speech therapy is accessed via a day centre, the Community Learning St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 16 Disability Team can be contacted at the local area office, and four service users see a chiropodist on a regular basis. The home has a contract with Boots for the provision of medicines and is supplied by its branches in Amersham or Luton. Medicines are prescribed by the services users GP and the prescription is held by Boots with a copy being retained in the home. Most medicines are supplied in the Boots monitored dosage system. Medicines are recorded on receipt and are stored in a locked cabinet in each service users’ bedroom. Keys are held by staff and no service user was self-administering at the time of the inspection. Staff are trained inhouse and have received training by Boots on its monitored dosage system. Further training is planned. A boots pharmacist checks stocks quarterly. References available to staff include the Royal Pharmaceutical Society Guidelines of 2003 and a British National Formularly. Medicine administration records examined were in order. However, it was noted that the date a tube ointment was opened was not recorded. This was also noted in the inspection of 2 March 2006. The home does not have a policy to guide staff practice with regard to the death of a service user. In discussion it was said that this is a difficult subject to address in this care area. The home benefits from being part of a an organisation which has a range of care services for service users with learning disabilities and it would be advisable for this matter to be progressed through the organisation’s policy making machinery. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures to ensure that complaints by service users, or by others on their behalf, are properly investigated by the registered manager. Policy and staff training aim to ensure that service users are protected from abuse. EVIDENCE: The home is subject to the policy and procedures of The Fremantle Trust in respect of concerns, complaints and protection. Through ‘Fremantle Feedback’ service users, relatives and others may relay concerns and complaints. No complaints had been received since the last inspection. Some families have expressed concerns about the plans for some service users to move on to supporting living arrangements. These concerns are understandable and are being addressed as that proposal develops. All staff have received training in the Protection of Vulnerable Adults (POVA). The home is subject to Fremantle Trust policy. The home did not have a copy of the ‘Safeguarding Vulnerable Adults - Interagency Policy and Procedures for Buckinghamshire’ which were published in January 2006 but undertook to obtain one soon after the inspection. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, comfortable, clean, homely and well maintained environment for service users. EVIDENCE: The home consists of two semi-detached houses adapted to form one home. Its external appearance is very much like those of other houses in the area. There is a bus stop within a short walking distance with buses to High Wycombe town centre and other areas. The nearest local shop is in a garage a short walk away. The gardens to the rear are sufficient in size for the present number of service users and staff. One garden is mainly lawn. The other has a number of seating areas and provides a comfortable area for service users to relax and for small functions. The interior of the home is domestic in size and appearance. Rooms vary in size and four are less than 10.0 sq. m. All bedrooms are single. There is no ensuite accommodation. There is one bathroom and one shower. The home is not suitable for a person in a wheelchair or who requires assistance with mobility. It is a very pleasant home which is bright and well decorated. All areas were clean and odour free on both inspection days. The home is comfortably St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 19 furnished and service users have chosen the colour schemes for their own rooms. It has a comfortable ‘lived in’ feel. Since the last inspection the kitchen and the staff shower room have been repainted. New carpets have been laid in rooms and in the porch areas. All areas of the home were clean, tidy and odour free. The laundry is suitable for the needs of current residents. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs sufficient staff to meet the needs of service users. Processes for the recruitment, induction, training and development of staff aim to ensure that service users are cared for and supported by staff with appropriate skills. EVIDENCE: The home had seven staff in post at the time of this inspection. Staff numbers are supplemented by bank staff when required. The duty rota takes service users activities into account. Current staffing maintains two staff on duty in the morning and afternoon and one sleep-in member of staff at night. The staff are experienced, all having more than three years in care work. Four staff had acquired NVQ2 or above and two were working towards NVQ 2. Staff turnover and sickness levels are reported to be low. The staff team are of mixed ethnic origins and include both male and female staff. Communication with residents is generally through spoken English but one resident is skilled in Makaton. Objects of reference, photographs and clip art are also in use. It is over two years since a permanent member of staff was appointed. Recruitment of staff is co-ordinated by the human resources office at Fremantle head office in Aylesbury. The office supports homes in recruitment St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 21 practice ensuring that they fulfil all requirements of the standards and Regulations. New staff would receive a copy of the GSCC codes of practice during induction. Existing staff should be provided with a copy. The Fremantle Trust maintains a comprehensive programme of induction, foundation and update training and provides support to staff pursuing NVQ training. According to the manager the training planned for the near future includes ongoing support for staff pursuing NVQ2, NVQ4 for the manager and assistant manager, updates as required for mandatory training, and continuing training and development on PCPs. Staff confirmed that the Fremantle Trust provides many opportunities for training and over the last 18 months one member of staff interviewed had attended training in NVQ2, first aid, breakaway, HACCP (Hazard Analysis and Critical Control Point), POVA and PCPs. Supervision is described as “informal” and takes place approximately every two to three months. Practice may be uneven. All staff have an annual appraisal. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the service is of a good standard and the home is run in the interests of service users. The home’s approach to quality assurance and to health and safety aim to ensure that it retains a focus on individual needs and to provide a safe environment for service users, staff and visitors. EVIDENCE: The registered manager is very experienced in the care of service users with a learning disability and in management. She is currently undertaking the NVQ4 in management. The registered manager has overall responsibility for the home and reports to a services manager. The registered manager believes that a number of practices in the home contribute towards the delivery of a good quality service. PCPs aim to ensure that the home provides services which meet the needs of individual service St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 23 users. The home endeavours to conform to the national minimum standards. The staff training programme aims to ensure that staff have the skills to meet the needs of users and to adapt to changing needs. The home participates in the Fremantle Trust internal quality assurance audit. It has held consultation meetings with families over cheese and wine and barbeques. There is an annual review which considers developments for each service user. The home receives feedback from service users and college (via a correspondence book). Managers from the Fremantle Trust carry our regular Regulation 26 visits with reports to CSCI. Comment cards received from relatives and health and social care professionals were favourable in their comments on the home. Relatives felt welcome, were kept informed of important matters, were aware of the home’s complaints procedure, had access to inspection reports and were satisfied with the overall service. One relative felt that there were not always enough staff on duty. Health and social care professionals expressed equally good levels of satisfaction. They felt that staff had an understanding of residents needs, that the home maintained good communications, that advice was appropriately incorporated into the plan of care and all were satisfied with the overall standard of care provided. A relative who happened to be visiting at the time of the inspection said that it was a good home, happy and safe. She described the staff as welcoming The staff induction and training programme of the Fremantle Trust offers basic and update training in moving & handling, food hygiene, first aid, infection control, medicines administration, fire safety, and protection of vulnerable adults (POVA). Arrangements for the maintenance of fire equipment, electrical safety, portable appliance testing (PAT), COSHH storage and information (data sheets from ASDA and through the Fremantle Trust) and gas safety are satisfactory. The deputy manager is the health & safety lead for the home and maintains links with the health and safety consultative and policy structure of the Fremantle Trust. Risk assessments cover a range of activities. The home had a contract for clinical waste with PHS at the time of this inspection. The home has an experienced manager, an experienced staff team and is part of a medium sized charitable trust which provides senior management support, and management systems including financial and human resource systems. The service is to be relocated in 2007 and consultation meetings and other events had been held with service users and their families. St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 2 X 3 X X 3 3 St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 25 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 2 Refer to Standard YA20 YA23 Good Practice Recommendations The date of opening is to be added to creams prescribed for service users. The registered manager should consider how the subject of ageing and death is to be addressed in this service. The registered manager should ensure that all staff are supplied with a copy of the GSCC codes of practice and are familiar with the codes. 3 4 YA21 YA31 St Hughs Avenue (22/24) DS0000023046.V300794.R01.S.doc Version 5.2 Page 26 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.V300794.R01.S.doc Version 5.2 Page 27 - 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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