Inspection on 29/05/07 for 46 Severn Avenue

This inspection was carried out on 29th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Severn Avenue 03/11/08

46 Severn Avenue 20/11/07

46 Severn Avenue 26/05/06

46 Severn Avenue 08/02/06

46 Severn Avenue 20/12/05

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 Nicola Hill Unannounced Key Inspection 29th May 2007 10:00 46 Severn Avenue DS0000008130.V336668.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 46 Severn Avenue DS0000008130.V336668.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. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 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 david.rogers@brandontrust.org www.brandontrust.org The Brandon Trust David Rogers 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.V336668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 30 years and over Date of last inspection Brief Description of the Service: Severn Avenue is a small home situated in a pleasant suburban area of Weston-super-Mare. The home provides support for up to 6 service users with varying degrees of learning disability. Fees are negotiated with the placing authority. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection the site visit allowed the inspector to speak with the residents and staff, and review records at the home. On arrival at the home one resident, who introduced her to the other residents who were at home at that time, showed the inspector around the ground floor. The inspector met all the residents; there have been no changes to the resident group since the last inspection. The evidence from the inspection process indicated that the service at the home is adequate and an improvement plan will be requested. What the service does well: What has improved since the last inspection? What they could do better: 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 6 The inspection process highlighted several areas where the home is deficient and these require improvement. The home must provide the Commission with an improvement plan for the service. There are 8 requirements and 6 recommendations made as a result of the inspection. The requirements were made because:There is no evidence to suggest that people using the service have any involvement in making decisions about their lifestyle. Where person centred planning has been undertaken the recorded goals and aspirations of residents have not been supported to achieving a positive outcome. The environment must be safe for the people using the service. The organisation has a responsibility to ensure that the service is monitored and is run in the best interests of the people using the service. 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. 46 Severn Avenue DS0000008130.V336668.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 46 Severn Avenue DS0000008130.V336668.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is in the process of reviewing their statement of purpose; individuals are provided with an accessible contract however there is no evidence that this is explained to them. EVIDENCE: The service user guide was available on the computer but was incomplete, and is currently being updated to reflect the service provided at 42 Severn Avenue. Changes in the statement of purpose should be notified to the Commission. Since the last inspection there have been no vacancies at the home and therefore the admissions process was not assessed on this visit. The Trust has issued a pictorial contract for each of the residents at the home. This has been placed in the Person centred planning file for each of the residents at Severn Avenue. The contracts have provision for residents names and pictures to be inserted, however none of the contracts had pictures and only three have residents’ names on them. There was no evidence to suggest that the contracts had been explained to the people using the service. The senior support worker explained that the contracts were new and that all of them would be appropriately completed and discussed with the people living at the home. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 9 The senior support worker and the inspector discuss the way in which the service addresses diversity and equality. All of the residents at the home currently are male, the age range is between 42 and 63 and all share the same ethnicity. The people using the service have a range of support needs, including support to attend religious worship. Currently two residents have expressed an interest in regularly attending church, and there was evidence that one resident attends church on a weekly basis. The service currently accommodates one person with an acquired head injury. 46 Severn Avenue DS0000008130.V336668.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): 6,7,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans, which are poorly developed, and out of date. There is evidence that they are written by care staff and management who do not actively involve the residents. The home does have a key worker system, however there is a lack of individual support and attention. Evidence indicates that residents are not supported to fulfil their aspirations. EVIDENCE: For the six residents currently living at the home there were daily files and Person centred planning files. The range of information available was comprehensive, and included evidence that residents has been included in initially setting personal goals and aspirations. The inspector discussed the content of the files with the senior support worker. Each resident had a key worker who took responsibility for ensuring that the goals and aspirations in the Person centred plans were met, and plans were reviewed on a regular basis with service users. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 11 The evidence from the files is that the care plans were not reviewed on a regular basis. The information in them was variable, for example, for one resident their identified need was listed as depression, and how staff met this need was encouraged fluid intake and resident to leave their room. For another person using the service the care plan appeared to be based on a nursing assessment (FANCAP), which had been undertaken in 2001 and last reviewed in January 2006. The senior support worker was aware that the care plans should be reviewed on a regular basis, especially where there are issues of behavioural management, however this had not been completed. The Person centred plan files contained the essential lifestyle plan for each resident; some were more complete than others. Where there were goals clearly identified, the evidence for achieving goals and the evaluation and review of the achievements was unclear. For example, one plan had a goal identified and evidence of implementation; another file had three goals identified but the review sheet for two of these goals had not been completed and the last entry for the third goal was dated March 2006. The manager of the home had signed the individual plans to indicate that they had been reviewed in January 2007, however there was no evidence to suggest that residents or their advocates have been involved in the process. In discussion with the staff team it was confirmed that plans are reviewed between the key worker and manager, and this was further evidenced in the house meetings minutes. These indicated that the residents were discussed at staff meetings and decisions about their lives are taken in this forum. The staff recognise that this was not an acceptable process, especially as the residents can communicate their needs. One member of staff stated, It feels as though we are going backwards. The daily records are written documents about the day-to-day life of the residents, it was noted that some of the language used was unprofessional, for example, a resident was referred to as vacant, whilst another record identified a resident as generally abusive. The two files of information held on each resident had not been completed satisfactorily or reviewed following the processes identified by the Trust. From the available evidence, the involvement of people using the service in taking decisions about their lives and planning for future is questionable, and the role of the home in supporting people to attain a chosen lifestyle is not acheived. There were risk assessments available, which had been completed on behalf of people using the service. These need to be reviewed alongside the care plans and personal goals so that residents are supported to take opportunities to explore new experiences. This is one of the goals identified by the manager for the service for 2007. 46 Severn Avenue DS0000008130.V336668.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): 11-17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally staff are aware of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills. Policies, procedures and guidance to promote individual independence are in place however the systems for checking practice are not always evident. The food at the home is of a good standard and meets the dietary needs of the people using the service. EVIDENCE: The person centered planning files identified the preferred lifestyle of the residents and had been initially completed with residents signing their agreement to the plan. The staff team at Severn Avenue have responsibility for ensuring the support is available for residents to achieve their chosen lifestyle. The evidence at the home does not indicate this is happening. The residents have a planned programme of activities, which includes attendance at day centres, such as the William Knowles Centre, the local college, or other community activities such as horse riding. The people using 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 13 the service each have a day service contract on their files, which acts as an indicator of the support available. The activity programme was difficult to correlate to the contracted hours; for example, one person attended two halfday sessions per week but had a contract for 19 hours per week. Day service provision outside the home is incorporated into established services and not always person centred, for example, one resident was listed as attending a weekly session in a local community centre but didn’t go as they didn’t like it. Four of the residents went out during the inspection, however the inspector had the opportunity to speak informally to them, and they confirmed that they were happy living at the home. One resident stated that they had plans to go on holiday, and was able to show us their holiday plan for a previous year. Generally the residents appeared settled, and the staff team acknowledged that whenever possible excursions away from home were organised. This was evidenced in the menu planning; as all the residents have a pub lunch on Friday, therefore a snack meal is planned on a Friday. Some of the residents at home enjoy smoking, however, there appears to be some confusion over the implementation of the government-smoking ban for work and public places. Currently, despite having an air purifier and a designated room for smoking, the residents are only allowed to smoke in the garden. Obviously this causes problems at night and early morning, and if the weather was poor. Staff confirmed that in these circumstances residents were prevented from smoking. The smoking guidance has ensured that residential care homes are exempt, and that providing that a designated room is provided which can be ventilated, residents are allowed to smoke on the premises. The inspector will provide the guidance to the home to ensure that people using the service are not excluded from their own home, and that their choices are supported. The service has reviewed their menus, and planned a four week menu which takes into consideration the known preferences for meals of the people using the service. The staff at the home have the menu and the recipes for the meals, as well as a weekly shopping list. This has simplified the process of meal preparation and shopping for the house. 46 Severn Avenue DS0000008130.V336668.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): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to health care services that meet their assessed needs both within the home and in the local community. There is evidence in the care plan of health care intervention. Medication records are generally up-to-date for each resident and medicines received, administered and disposed of are recorded. EVIDENCE: The people using the service have care plans and person centered plans which both provide information relating to the residents preferences for personal care. The quality of information is variable, and evidence of user involvement is difficult to establish. For example, if a resident is incontinent and requires a continence aid, the type to be used was not identified nor the method used to keep the pad in place. However, all of the residents appeared well groomed with coordinated clothing. The person centered plan folders have a section for health action planning which is in an accessible format and contains the documentation necessary to identify current issues, be proactive for health screening, and for continuing 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 15 health care services such as opticians, dentists, chiropody. There is also a specific appointments record and a recording document to be completed when residents attend appointments which also identifies any follow-up action or medication prescribed. In the daily files there is also a health record. The inspector reviewed the health care documentation for all the residents. The documentation was incomplete, and as it was split between two files it was difficult to track any health care issues. However, from using the daily records and the diary the inspector found evidence of regular health reviews with the consultant psychiatrist, and when the resident had a health problem there were records of visits to the GP. This was discussed with the senior support worker, because the documentation gave a picture of the home of being reactive to changes in the health of residents, and not pro-active in health screening . The people living at Severn Avenue may have additional healthcare needs such as mental health issues or physical health problems. The inspector noted that there was additional information available for staff to read and enhance the service and support for the residents. The issue of monitoring weight was discussed as some of the people using the service are quite sedentary and need motivation to take exercise. One resident has a weight loss plan in place however this was not being completed and therefore the weight loss monitoring plan could not be evaluated. The home uses the Boots unit dosage medication system for regular medication; the system was checked and found to be accurate and up-to-date. The when required medication stock was checked against the records held at the home, this was also found to be accurate and up-to-date. The records for the when required medication indicated that this was rarely used, and there were protocols in place which would support staff to make a decision when using medication would be appropriate. 46 Severn Avenue DS0000008130.V336668.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): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others associated with the home understand how to make complaint. EVIDENCE: The Brandon Trust has an accessible complaints procedure for service users. The home has received no complaints from the service users or their representatives. All staff undertake training in awareness of abuse as part of the induction to the Trust. The organisation also provides regular updates for staff to attend. There have been no issues at the home requiring referral under the adult protection procedures. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 17 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): 24,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home provides a physical environment than meets the needs of the residents; maintenance tends to be reactive rather than proactive. The home is generally clean and tidy, infection control precautions are poor. EVIDENCE: The inspector walked around the building with the senior support worker and noted the following for action:The window frames were quite mouldy, this had extended in some areas to the net curtains and window sills; some of the rubber seals are beginning to rot. The mould should be removed and an assessment made on the condition of the windows. The upstairs bathroom ceiling has a large area of mould which should be removed and made good. The flooring in the downstairs bathroom has been patched and therefore is not sealed and has gaps which allows dirt and waste matter to collect in it. These gaps should be sealed to promote effective hygiene in the home. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 18 The seat in the downstairs shower is broken and is a hazard to any person using it, this should be mended as a matter of urgency. The inspector was informed that the downstairs corridor carpet was being replaced, and it is planned that the corridors are redecorated. The replacement of the carpet is an outstanding requirement from the previous inspection. The procedures in place for hand washing and infection control were patchy, for example, liquid soap was available in both the laundry and kitchen but no disposable hand towels were in place. The bathroom areas did not have any hand washing facilities for staff. The residents have in the past blocked toilets with hand towels however the infection control and hand washing facilities currently are inadequate, and the home must consider other alternatives such as alcohol based gels. The laundry facilities are situated on the first floor and are adequate for the needs of the people using the service. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 19 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service ensures that all staff within its organisation receive relevant training that is targeted at focus on improving outcomes for residents. EVIDENCE: The staff rota indicated that there were a minimum of two staff between 8 a.m. and 9 p.m., and one member of staff who remains awake and provides support at night. It was noted that the manager of the home is included in the rota and works night shifts which impacts on the managerial time with staff. The staff recruitment records are held at headquarters, the Trust has a robust recruitment procedure and ensure that all staff attend the corporate induction training. The staff training records held at the home were a mixture of individual records and computer records. The evidence did not provide a clear picture of training for staff and it was unclear if the standard of 5 days per year had been achieved. The inspector would advise that one up to date record be maintained. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 20 The majority of staff working at the home have either NVQ 2 or NVQ 3 in care and are supported to attend additional training specific to the needs of the people using the service. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 21 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): 37,38,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are not included in planning service delivery or assessing the quality of service provided; the available evidence indicated that this service is not user led. EVIDENCE: The manager for the service was not present at the time of the inspection, However, he is an experienced manager who has managed other Brandon Trust care services. There was evidence that the manager undertook regular training. The inspector spoke with residents who identified the manager as very nice and a good man. The staff that spoke with the inspector felt that the manager had stabilised the home and that the staff structures were clear. The issues for staff were related to teamwork and the leadership of the home. The staff comments to the inspector were I come in and do my job and go home, I 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 22 try not to get involved in politics and we seem to have lost sight of why we are here. The staff team recognised that there were opportunities through the staff meetings to raise issues, and it was confirmed from the notes of the last staff meeting that the issue of teamwork and working together for the same outcome had been raised. The staff stated that these issues had been raised before and not much progress had been made towards achieving a cohesive staff response. Examples were given to the inspector of how this impacted on the quality of service for the residents, for example, depending on who was on duty, residents were supported with activities outside the home. One person commented that it was not unusual for staff to sit with residents and watch television, and whilst this was a communal activity, there was very little interaction with the residents. Access by residents to all areas of the home was also identified as an issue as some support workers allowed residents to access the kitchen whilst others did not. The staff team recognised that the manager was approachable but also stated that there was a lack of leadership and this meant that some staff had adopted the attitude of if I dont do it no one will pick me up on it, so why bother?” In relation to the person centered planning and the support for residents to achieve goals, one person stated that they recognised it was not acceptable that a resident’s personal goal to visit a local facility, which was within 10 minutes walk of the home, had not been achieved. They recognised that it was a team responsibility to support residents in their life goals but felt that more direction to the staff team was needed. The residents do have a house meeting, where various subjects are discussed, however, the level of input into the day-to-day running of the home by residents is influenced by their support needs rather than by expressed choices. The Trust has a quality assurance system, which should provide selfmonitoring, review and development of the service. The senior support worker stated that the quality standards had been assessed for the year but could not find evidence of this. The annual development plan for the home had been written by the manager, the senior support worker could not find the documentation to support the achievement of the objectives identified. The feedback from people who use the service is generally verbal and not documented. The Trust has robust systems to ensure that staff have adequate health and safety training, and attend regular updates. The fire safety procedures at home were examined and seen to be fully implemented, however, the fire safety risk assessment was not available. The risk assessments for the premises appear to be in the process of being reviewed. Accidents and injuries at the home are recorded appropriately and action taken to prevent reoccurrence. The infection control measures at the home are inadequate and need reviewing to ensure that personal protective equipment and universal infection control practices are implemented. 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 23 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 2 2 X 3 X 4 X 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 2 X X 2 X 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 YA6 YA7 Regulation 14,15,24 Timescale for action The registered person must write 29/08/07 a care plan for each resident which demonstrates how the residents support needs will be met. The plan must indicate resident involvement in the process. The plan must be kept under review. The downstairs corridor and 29/11/07 entrance hall carpeting should be replaced. (This requirement is repeated from 08/08/06) At the time of inspection, the manager was unable to find the statement of purpose for the home. The Inspector requires that a statement of purpose be found or written within the period defined. Any changes to the service as stated in the statement of purpose must notified to the Commission. (This requirement is repeated from 08/08/06) 29/08/07 Requirement 2. YA24 23 2 b 3. YA1 41a 6b 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 25 4. YA38 21 24 5. YA39 24 1 a b 6. YA30 13 3 7. YA11 YA12 YA13 YA16 14 2 a b 15 1 2 16 2 m n 8. YA24 23 1 a 23 2 c The registered person must have systems which monitor the service provided and work toward improving service provision for the residents. The registered person must have systems in place to review the quality of service provision which includes consultation with people who use the service. Universal infection control measures must be made available and used by the people working at the home. The people using the service must have individual social activities needs assessed. The home must support the individual to follow chosen activities and use community resources. People who use the service should be supported to attend religious worship at a place of their choice. The physical environment of the home must be improved. The window frames were quite mouldy, this had extended in some areas to the net curtains and window sills; some of the rubber seals are beginning to rot. The mould should be removed and an assessment made on the condition of the windows. The upstairs bathroom ceiling has a large area of mould which should be removed and made good. The flooring in the downstairs bathroom has been patched and therefore is not sealed and has gaps which allows dirt and waste matter to collect in it. These gaps should be sealed to promote effective hygiene in the home. DS0000008130.V336668.R01.S.doc 29/11/07 29/11/07 29/08/07 29/08/07 29/08/07 46 Severn Avenue Version 5.2 Page 26 The seat in the downstairs shower is broken and is a hazard to any person using it, this should be mended as a matter of urgency. 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 YA16 Good Practice Recommendations The inspector recommends the home consider the use of some form of movement activated chining device so that staff are aware of people passing in and out of the front door.(This recommendation is repeated from the last inspection report). The people who use the service should have their contract of residency explained to them and sign their contracts. Residents should be supported with risk taking to facilitate individual development i.e. access to the kitchen. The inspector would recommend that the health action plan documentation provided by the organisation be fully implemented. Health screening should be implemented for people who use the service. Staff training records are kept in one place to provide evidence of a well trained work force. 2. 3. 4. 5. 6. YA5 YA9 YA19 YA19 YA35 46 Severn Avenue DS0000008130.V336668.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 46 Severn Avenue DS0000008130.V336668.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. 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