Inspection on 15/01/07 for 281 - 287 St Georges Road

This inspection was carried out on 15th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

281 - 287 St Georges Road 17/03/09

281 - 287 St Georges Road 12/06/06

281 - 287 St Georges Road 24/01/06

281 - 287 St Georges Road 13/09/05

281 - 287 St Georges Road 12/10/04

281 - 287 St Georges Road 28/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 281 - 287 St Georges Road 281, 283, 285, & 287 St Georges Road Hull East Yorkshire HU3 3SW Lead Inspector Christina Bettison Unannounced Inspection 15th January 2007 09:30 DS0000000916.V325773.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 DS0000000916.V325773.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. DS0000000916.V325773.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 281 - 287 St Georges Road Address 281, 283, 285, & 287 St Georges Road Hull East Yorkshire HU3 3SW 01482 618096 01482 329337 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) Avocet Trust Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000000916.V325773.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To retain one service user over 65 years of age. Date of last inspection 12th June 2006 Brief Description of the Service: The service at 281-287 St Georges Road is managed by Avocet Trust who rent the premises from Sanctuary Housing. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 281-287 St Georges Road consists of four separate units registered to provide care for 12 service users. The home is situated just off the Hessle Road shopping area to the west of the city. Two of the units are for 4 service users and two are for 2 service users, all accommodated in single rooms and each house has its own separate garden area. Three houses have a relaxation room and the house without has an additional lounge. Each house also has a communal lounge/dining area, kitchen, laundry and bathroom. One house has an additional bathroom. There are a variety of shops, pubs, GP surgeries and post office all within walking distance. Public transport to various parts of the city is easily accessible and in addition some of the service users have their own car arranged through their mobility benefits. There are parking facilities on-site. Weekly fees range from £856 - £1,000 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000000916.V325773.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced second key inspection and took place over 1 day in January 2007. During the visit the inspector spoke to the manager and staff. The service users that live at St Georges Rd have complicated needs and are not able to tell the inspector of their views therefore in this report comments from relatives, have been used to help to form a view whether service users needs are met or not. Observations of care practice were made to assess service user satisfaction. The inspector looked around the home and looked at some records. Information received by us since the previous inspection was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home since the previous inspection. The site visit was led by Regulation Inspector Mrs. C. Bettison and lasted for six hours. Following the previous inspection the CSCI had serious concerns about the standard of care and management at the home however in the last 7 months the manager and staff team have made significant improvements to the standard of care at the home and should be commended for this. During the course of the inspection the inspector met with visiting relatives who confirmed that the standards of management and care at the home had improved under the current manager. They stated that they were very happy with the care of their son; they visit every day and are always made to feel welcome. They also stated that their sons recent health needs were met in a prompt manner. What the service does well: Avocet Trust provides accommodation and personal care support and is a good service for adults with a learning disability and other needs. The main aim is to help people to develop as much independence as possible, whilst helping them to be more confident and access community facilities. The houses are in the local community and are on a bus route making all leisure facilities and shops easy to get to. DS0000000916.V325773.R01.S.doc Version 5.2 Page 6 All service users have a single room that is to their own taste, in a house for no more than 4 people giving them a home and private space were they can spend private time or have visitors. Families are encouraged to be involved and are welcomed when visiting their relative. Service users enjoy a healthy diet and their likes and dislikes listened to. What has improved since the last inspection? Although there are some requirements still not fully met and identified within this report, the manager and staff team have made significant improvements in the quality of the service provided and supporting paperwork and it is felt that within the current management arrangements the home has the capacity to improve and meet the remaining requirements within a reasonable timescale. Each person living at the home has a detailed individual plan, which helps staff to know how their needs must be managed. Important information, e.g. risk assessments and behaviour management plans are in place which help staff to provide care to meet service users needs. The complicated health needs of service users is being met and special health advice is followed, however this would be further helped by the development of health screening and health action plans. Medication is now being handled safely and most of the staff have received medication training helping service users to be safe from harm. At the time of the inspection the homes manager had been there for 7 months this gives service users and staff a sense of stability. The manager and staff are meeting the diverse needs of service users by providing activities and meals that meet their individual needs. Staff are meeting with their manager on a regular basis which offers them ongoing support and direction in how to meet service users needs. Team meetings are being held regularly to give staff chance to voice their opinions and have say in the running of the home and relatives meetings are also being held regularly. The manager is aware what training the staff need. More than 50 of the staff team are now qualified to NVQ level 2 or above. Staff have had special training for the needs of the service users. DS0000000916.V325773.R01.S.doc Version 5.2 Page 7 The home is safe, comfortable and homely and provides service users with a nice place in which to live. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000000916.V325773.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000000916.V325773.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 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 appropriately assessed to ensure that the home is able to meet their ongoing and changing needs. EVIDENCE: There had been no new service users (who would have had their needs assessed) come to stay at St.Georges Rd since the previous inspection. However previous inspections have identified that all service users have an assessment undertaken by the local authority in their care file that was completed before their move to the home. These assessments are all in the process of being reviewed, updated and amended by the Local Authority as required to accurately identify service users current needs and ensure that the home is able to meet them. DS0000000916.V325773.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have detailed individual plans that reflects their full range of needs; choices etc. ensuring that their complex needs will be met. Service users that display behaviours that pose a risk either to themselves or others have behaviour management guidelines to evidence that they or their representatives have agreed to any limitations on facilities, choice or human rights. EVIDENCE: At the previous inspection it was noted that the manager and the staff team had made a good start in the development of service users plans and all of the associated documentation that goes with this to ensure that service users needs are met. At this time the manager needed to ensure that this was in place for all service users. DS0000000916.V325773.R01.S.doc Version 5.2 Page 11 The manager and the staff team have worked very hard in the last 7 months to ensure that this is achieved. Three care files were examined, one from each house within the complex, as part of the inspection process. The service user plans have been developed to include everything that is detailed in the local authority assessment/care plan and now detail accurately what staff need to do to meet service users needs, this was consistent across all three care plans examined. The manager assured the inspector that this was the case for all service users and that all plans could be inspected if required by the inspector. The manager stated that she had provided training for all of the staff on care planning and this was evident in the quality of the care planning and supporting documentation. All three care files examined contained a personal information sheet detailing all relevant people in the service users life and where they could be contacted, a detailed likes and dislikes sheet, comprehensive individual programme plan and supporting management plans and risk assessments that all detailed what staff needed to do to meet the service users complicated needs. There was evidence in all care files of steps being taken towards meeting service users personal development needs, e.g. one service users dad told the inspector that the service user had previously enjoyed participation in the local community and going out for car rides with his dad. Following the service users period of ill health this had resulted in him not wanting to go out of the house. It was documented in his individual plan that the staff were assisting the service user to re commence these activities but taking it slowly and at the service users own pace. For one service user there were risk assessments to cover choking, moving and assisting and the risk of falls and for another there were risk assessments to cover moving and assisting, going out in the community and avoiding crowded spaces and for ensuring safety when bathing. However the inspector advised that for one service user it was identified in the assessment that they were at risk of ingesting toiletries and there should be a risk assessment to cover this and for another service user who had some pressure area care there should be a risk assessment to cover this. The manager agreed and said that she would put these in place immediately. All three service users had been reviewed by the local authority. DS0000000916.V325773.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. 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. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of activities within the home and community means that all service users have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: The inspector was informed that none of the service users are engaged in work placements. DS0000000916.V325773.R01.S.doc Version 5.2 Page 13 The inspector was informed that some service users enjoy an active social life, such as bowling, swimming, shopping, visits to the hairdresser, walks and out for meals at the pub, visiting friends, one of the service users support Hull City AFC and attends the home games, and this was evident in the care files examined. Recent activities have included a Halloween and Christmas parties, Christmas shopping both locally and at Meadow hall shopping centre in Sheffield, trips out to Flamingo land, Butlins, Avocets caravan at Skipsea and attendance at a service users 40th Birthday party. Service users are supported to either visit their parents/relatives homes or are visited by them at their home and contact is welcomed. One of the relatives spoken to said that he visits his son every day and is always made to feel welcome by the staff and new manager. For another service user the staff had made attempts to re locate their family who they had lost touch with, this had been successful and the family (who live away from the area) now visit their relative every 2-3 months. Some service users attend Avocets five senses day service. The inspector was informed that the manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. For two of the care files examined there was evidence of the involvement of the dietician and all recommendations had been followed and incorporated into the Individual plan. There was robust monitoring of weight and food and fluid intake for those service users that needed this. DS0000000916.V325773.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the service users are assessed, identified, clearly documented and are being met by the service, health colleagues and staff. The medication at the home is well managed promoting good health. EVIDENCE: Three service users care files were examined as part of the inspection process this evidenced that service users healthcare needs are adequately being met and that access to dentist, optician, audiologist, chiropody, community nurses, consultants and therapists was being facilitated on a routine basis for service users. One service user had recently experienced a period of poor health, the service users relative informed the inspector that all appropriate health specialists/investigations had been accessed and carried out resulting in a diagnosis and appropriate medication and treatment being prescribed. The DS0000000916.V325773.R01.S.doc Version 5.2 Page 15 service user is now in much better health and mood resulting in a better quality of life. It was documented in a Regulation 26 visit report by a Trustee of Avocet that for another service user who had been in hospital for a planned operation that the staff had provided 24 hour support whilst she was in hospital and that the hospital staff had commented “most caring and dedicated staff team they have ever seen.” Health screening had been completed however the quality of this documentation was poor and needed re visiting. The manager informed the inspector that the staff had completed them but had not received any training to do this so she intended to provide them with the training and then ask them to complete them again. The Community Team Learning Disability have been approached to assist in the preparation of Health Action plans. Each service user must have health screening undertaken and the development of a health action plan to ensure that their health needs and the provision of specialist support is planned for and provided. There are currently no service users self-medicating. There are written policies and procedures in place for staff to adhere to regarding administration of medication. Where individuals are prescribed controlled drugs, these are well managed and monitored by the staff and the use of a controlled drugs register and cabinet that meets the requirements of the legislation. PRN protocols were in place to give staff clear instructions of when and what dosage needs to be administered. Other medication records were examined as part of the inspection and found to be in good order. The manager completes an audit of the medication every Monday morning to pick up any discrepancies and takes immediate action, there is currently a disciplinary investigation ongoing regarding missing medication, however no service users are at risk as a result of this. The manager confirmed that all but two of the new staff had completed the administration of medication provided by the local authority that includes a competency check or a workbook to be completed following the training to ensure staff understand their responsibilities. All accidents are logged and the manager undertakes a monthly audit of these and takes action where required. DS0000000916.V325773.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints made to the manager of the home are handled appropriately and relatives are confident that their concerns will be listened to, taken seriously or acted upon. The staff team are aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these and the improvements in the individual plans, behaviour management strategies and attention to health needs ensures that service users are protected from abuse, neglect and harm. EVIDENCE: There had been two complaints to the manager of the home since the previous inspection, which had been investigated fully and resolved. The manager keeps a record of complaints with detail of any investigation and action taken. There have been minimal staff changes at St Georges Rd since the previous inspection and the stability of the manager in the home has led to a more stable and consistent staff group who are able to meet service users needs. From examination of the training records it was evident that all staff but two new ones have completed training in the Protection Of Vulnerable Adults Policies and Procedures and therefore understand their responsibilities within this and the detailed individual plans, behaviour management strategies and DS0000000916.V325773.R01.S.doc Version 5.2 Page 17 attention to health needs ensures that service users are protected from abuse, neglect and harm. DS0000000916.V325773.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The environment provides service users with comfortable, homely, welldecorated and safe surroundings in which to live. EVIDENCE: 281-287 St Georges Road consists of four separate units registered to provide care for 12 service users. The home is situated just off the Hessle Road shopping area to the west of the city. Houses 285 and 287 are for 4 service users in each house and houses 281 and 283 are for 2 service users in each house, all service users have single rooms DS0000000916.V325773.R01.S.doc Version 5.2 Page 19 that are nicely personalised and each house has its own separate garden area. One of the gardens has been upgraded to provide a patio and barbecue area. 287 St Georges rd. At the previous inspection the lounge and hallway have been redecorated and new carpets fitted. This house has received a new tumble dryer, fridge and microwave and the bath has been repaired since the previous inspection. 285 St Georges Rd Since the previous inspection this house has had new flooring fitted in the hall and lounge, new bedroom furniture and a new changing table has been purchased and it is intended to replace the bath as the existing one has been condemned. 281/283 St Georges rd. At the previous inspection a requirement was made that the bath in 281 St Georges Rd requires repair or replacement this has now been repaired. The kitchens in all of the houses are still looking tired and dated and would benefit from replacement or refurbishment. The manager informed the inspector that Sanctuary Housing (who are the landlords) intend to refurbish the kitchens soon. Comments received from relatives at the previous inspection included “ when I visit the home is always clean and is a working home. The kitchen is always a hub of activity usually involving the clients. The feeling I get is that it is warm and friendly and I am always made to feel most welcome.” DS0000000916.V325773.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 32, 35 and 36 Service users needs are met by a stable, competent and qualified staff team that are aware of service users complex needs and are able to meet them. EVIDENCE: The manager reported that since the previous inspection two staff had left St Georges rd, one due to ill health and one preferred to work as bank staff. One member of staff is currently suspended. Another full time vacancy has been appointed to but is awaiting return of their Criminal Records Bureau clearance in order to commence employment. Two new staff have been appointed, new staff where required had completed their induction in learning disability (LDAF) and the two new staff appointed are registered for induction. DS0000000916.V325773.R01.S.doc Version 5.2 Page 21 From examination of records, discussion with staff and observation it was evident that staff work to support the written aims and objectives of the home. It was also evident from discussion with staff that they knew how to meet the needs of service users and there was evidence in care files of the involvement of other agencies with specific expertise. Staff recruitment files were not examined during this inspection as they were assessed at the previous inspection and NMS 34 was met. Most staff were up to date with their mandatory training and updates were planned, including infection control. Although staff have completed the medication training, the manager stated that they were having trouble obtaining the certificates of completion from the Local Authority. All staff have now had briefings on the Protection of Vulnerable adults. The majority of staff had completed training in how to manage difficult behaviour, senior staff had completed risk assessment training, some staff had completed makaton training, all seniors had completed IP/care planning training, and training had been provided in bowel massage and postural management. The numbers of staff that have completed National Vocational Qualifications has greatly improved, the home has 28 staff in total, 13 staff have completed NVQ 2, 4 staff have completed NVQ 3 with three more staff working toward this, there is one NVQ assessor within the home and the manager has got NVQ level 4.The inspector was informed that there are another 5 staff to commence NVQ level 2 and one to commence NVQ level 3 in February of this year. These Figures exceed the 50 requirement. The supervision records of nine staff were examined as part of the inspection process. The provision of supervision has improved both in terms of quality and quantity. Since the previous inspection in June 2006 the majority of staff had received three sessions with the exception of two staff supervised by a particular senior member of staff. This is being dealt with by senior managers at Avocet Trust. None of the staff had received an annual appraisal that identifies their training needs and this must be addressed along with the outstanding requirement for the manager to develop a training plan for the home. DS0000000916.V325773.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides effective leadership; guidance and direction to staff to ensure that service users receive consistent quality care promoting and safeguarding the health, safety and welfare of the people using the service. EVIDENCE: DS0000000916.V325773.R01.S.doc Version 5.2 Page 23 The manager of the home - Deborah Grey has been in post since June 2006 and as yet is not registered with CSCI. She has a variety of skills, relevant qualifications and experience and has managed care homes in the past. She has NVQ level 4 and the registered managers award. At the previous inspection the manager informed the inspector that she was well aware of the requirements previously made and was working towards ensuring they were all met. Deborah and the staff team have vastly improved the standards in the home and are providing a good level of care and protection to the service users that live in the home. As part of the inspection all health and safety and the maintenance certificates were examined, all were available and up to date. Avocet have developed a quality assurance system for use within the home and several meetings have taken place with relatives to discuss the running of the home and the manager undertakes a range of audits and checks however this needs to be further developed to ensure a systematic and planned approach to quality assessment, that all stakeholders are given an opportunity to contribute to the ongoing development of the service and that areas for improvement are clearly documented and action taken to improve evidenced. All of the Policies and procedures have been updated and it is Avocet’s intention to hold workshops to introduce the new procedures and ensure all understand them and work within them. Regulation 26 visits are undertaken by the trustees of Avocet Trust, the manager has commenced staff meetings and house meetings and management meetings take place monthly. Staff spoken to commented that the manager is very supportive and is steadily helping to build the staffs confidence. They also stated that she had given staff the opportunity to develop their skills by providing training and delegating to staff and that she is very approachable. The home is safe and comfortable for people living there and provides a clean, comfortable and homely environment. DS0000000916.V325773.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 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 x 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 3 2 3 x 3 x DS0000000916.V325773.R01.S.doc Version 5.2 Page 25 yes 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. 1. Standard YA19 Regulation 13 (1a and b) Requirement The registered person must ensure that health action plans are prepared for service users in partnership with health professionals. (Timescale of 31/08/06 not met) The registered person must ensure that risk assessments are in place for all areas that pose a risk to service users. (Timescale of 31/08/06 not met) The registered person must ensure that a training plan is developed for the staff team in the home. (Timescale of 31/03/06 and 31/08/06 not met) The registered person must ensure that all staff have an individual training and development assessment and profile that is linked to the aims of the home and service users needs. The registered person must further develop the quality assurance system within the home that ensures the views of service users and their families are taken into consideration and DS0000000916.V325773.R01.S.doc Timescale for action 30/06/07 2. YA9 13 (6) 30/06/07 3. YA35 18 30/06/07 4 YA35 18 30/06/07 5. YA39 24 30/06/07 Version 5.2 Page 26 6 YA42 13(4) the service is continually improved. (Timescale of 30/11/06 not met) The registered person must provide evidence of design solutions to control the risk of legionella. 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA39 Good Practice Recommendations The registered person must ensure that the manager of the home is registered with the CSCI. DS0000000916.V325773.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000000916.V325773.R01.S.doc Version 5.2 Page 28 - 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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