Inspection on 20/12/05 for 46 Severn Avenue

This inspection was carried out on 20th December 2005.

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

46 Severn Avenue 03/11/08

46 Severn Avenue 20/11/07

46 Severn Avenue 29/05/07

46 Severn Avenue 26/05/06

46 Severn Avenue 08/02/06

46 Severn Avenue 05/10/04

46 Severn Avenue 25/05/04

46 Severn Avenue 13/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 46 Severn Avenue Weston Super Mare North Somerset BS23 4DQ Lead Inspector Paul Grey Unannounced Inspection 20th December 2005 10.30 46 Severn Avenue DS0000008130.V274106.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 46 Severn Avenue DS0000008130.V274106.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. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 46 Severn Avenue Address Weston Super Mare North Somerset BS23 4DQ 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) 01934 626731 0117 9699000 The Brandon Trust Mrs Beverley Cole Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 30 years and over Date of last inspection 2nd November 2005 Brief Description of the Service: Severn Avenue is small service based in a suburb of Weston super mare. Located within easy access of the town, local bus routes and the sea front the home offers good access to local facilities. Severn Avenue provides care for up to 6 service users with learning disabilities. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector found a settled and well cared for service user group, well presented home and sufficient documentation to meet national minimum standards. The inspector noted a number of minor shortfalls in documentation, particularly regarding staff supervision. The inspector spoke with the current acting manager regarding these. The inspector notes the home has gone through an unsettled period without an established manager, this has been addressed by the Brandon Trust. The inspector will revisit the home on announced inspection in April or May to review the service in some depth. What the service does well: 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. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 6 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 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 7 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, Service users needs and aspirations are assessed by the staff team EVIDENCE: The inspector noted extensive assessment documents and the introduction of some of the Brandon Person Centered Planning format. The inspector noted assessment documentation meets national minimum standards. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 8 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, 9 Service users know their changing needs are reflected in their plan of care. The service supports service users make decisions about their own life. The service supports service users to take reasonable risks as part of independent living. EVIDENCE: The inspector audited 2 care files. The inspector noted plans of care were drawn from the service user assessment and based (partially) in information obtained from the person centred planning document. Generally, care plans were reviewed appropriately and appeared to reflect care offered within the home. Any potential restrictions of freedom was care planned and risk assed. The manager informed the inspector that staff support service users to make decisions about their own lives. This was reflected in service user plans and within the statement of purpose. The inspector audited risk assessments in 2 service user files. The risk assessments were comprehensive, up to date and designed to support service 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 9 users achieve a reasonable standard of living. Risk assessments met national minimum standards. 46 Severn Avenue DS0000008130.V274106.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): 11,13,14 The home provides service users with opportunities for personal development. The home helps service users to become part of the local community. Service users are supported to engage inappropriate leisure activities. EVIDENCE: The Inspector noted evidence from service users, staff statement and care planning documentation of a range of activities and practical life skills training for service users. The Inspector noted service users are also involved in a day rota of tasks around the home. These are not unduly onerous and maybe supported by staff. The home support service users to participate in the local community, this may involve visits to the Playhouse, so more local swimming pool or town centre. Service users may also help with shopping and are supported in a range of other activities within the community. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 11 The home has a range of leisure activities available to service users, these are mainly restricted to audiovisual entertainment. Service users are supported and encouraged to attend an external holiday supported by a member of staff. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 12 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 The home support service users to receive a personal support in the way they prefer. The home support service users to meet the physical and emotional health needs. EVIDENCE: The ethos at Severn Avenue encourages staff to support service users privacy, dignity and independence. The inspector saw documentary evidence of this in the policies and procedures file and within the care files. The deputy manager informed the inspector that staff are encouraged to be sensitive to the expressed choice of service users in relation to their chosen clothing or hair style. The Inspector noted contact details for the local GP, relevant information regarding the service users general health and involve external agencies. The home monitors service users health and any potential shortcomings or complications are referred to an appropriate third-party if the home is unable to care the service user. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 13 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): 23 The home protects service users from abuse. EVIDENCE: The home has appropriate policies and procedures in place to protect service users from abuse. The inspector noted the home has access to Brandon Trusts policies and procedures and that the Somerset No secrets document was in the office. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 14 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, 26, 28, 30 The service provides a homely, comfortable and safe environment. Service users bedrooms promote their independence. The homes communal spaces supplement at the service users bedrooms. The home was clean and hygienic throughout. EVIDENCE: Severn Avenue there is a large domestic property. The property appears to have been extended to meet the needs of the service users. The premises are safe, airy bright and pleasant with sufficient bedrooms and communal areas to comply with national minimum standards. The home has a planned maintenance program. The Inspector visited service users bedrooms whilst inspecting the premises. The service users bedrooms will clean tidy and personalised to reflect the service users taste. Furnishings and fittings comply with national minimum standards. Service users were supplied with a key for their own bedroom. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 15 The home has a range of safe comfortable communal areas. A pleasant domestic sitting-room, dining room and outside garden area. The homes kitchen and laundry area are on the domestic scale, in good working order and well maintained. At the time of inspection the premises were clean, hygienic and free from the offensive odours. The Inspector noted laundry facilities were sited away from the kitchen area. The home has sufficient and washing facilities. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 16 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): 31, 33, 36 The homes service users benefit from clear staff roles and responsibilities. The home support service users with an effective staff team. At the time of inspection, staff were not receiving a sufficient supervision to meet national minimum standards. EVIDENCE: The staff at the home have clearly defined job descriptions, and understand their roles within the home. The job descriptions are supplied by the Brandon trust. Staff knew the service users well and had developed a positive relationship. During the time of inspection the Inspector noted there were sufficient staff to meet the service users needs. Staffing was sufficient to allow service users one-to-one time, supported time off the premises, the manager informed the Inspector staff numbers would be affected by service users level of need. When auditing supervision notes, the Inspector noted that 3 staff had insufficient supervision sessions. The Inspector notes the managers comments that given the lack of registered manager, a number of such things have not been addressed. The new manager has made an undertaking to address staff supervision, as a consequence the Inspector has not required a 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 17 plan of action at this stage. If this is not addressed by subsequent inspections the Inspector would make this subject to requirement. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 18 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, 38, 40 Service users benefit from a well-run home. Service users benefit from the ethos leadership and management approach of the home. Service users rights and best interests are safeguarded by the homes policies and procedures. EVIDENCE: The current acting manager, Mr David Rogers is an experienced manager and is applying to the commission for the post of registered manager at the home. The management of the home is positive, inclusive and open toward service users. Management processes within the home a clear and understandable. The Inspector audited two policies and procedures at random. Both were present, up-to-date and complied with current legislation. 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 19 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 20 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 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 3 X 3 X X X 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 21 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. Refer to Standard Good Practice Recommendations 46 Severn Avenue DS0000008130.V274106.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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