Inspection on 08/02/06 for 46 Severn Avenue

This inspection was carried out on 8th February 2006.

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

The inspector found 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 3 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 29/05/07

46 Severn Avenue 26/05/06

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 Paul Grey Announced Inspection 8th February 2006 09:30 46 Severn Avenue DS0000008130.V278080.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.V278080.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.V278080.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.V278080.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 20th December 2005 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. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector conducted this inspection in the presence of the homes new manager, Dave Rogers. During the inspection the Inspector spoke with 2 staff members, a day care worker, 3 service users and the manager. The Inspector also completed a tour of the premises and reviewed various documents within the home. The Inspector noted that the home appears to have passed through an unsettled transition period with change in management. The Inspector notes feedback from service users remains positive. The Inspector found a stable, well organised service in meeting its statement of purpose. The Inspector commends the new manager on his work so far. Severn Avenue remains a strong service and continues to meet both its remit and national minimum standards. What the service does well: What has improved since the last inspection? What they could do better: The home had gone through a range of management transitions, which appeared to have unsettled the staff team. The Inspector noted that the staff feel happy and settled at the home and that the new manager appears to have settled in well. As a result of this transition period there have been a number of minor documentation issues which the new manager is now addressing. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 6 These were not particularly major and will be easily addressed by the manager. At the time of inspection, the Inspector noted no significant flaws in this 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. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Potential service users are provided with the information they need to make an informed choice about the home prior to moving in. The home can demonstrate its ability to assess the needs and aspirations of prospective service users. Prospective service users know that the home can meet their needs and aspirations. EVIDENCE: At the time of inspection the home was unable to supply an up to date statement of purpose. The Inspector has seen the statement of purpose previously. However one could not be found on the premises delete of and this needs to be addressed. The Inspector would also look to see that the new statement includes details such as the new manager, and any updates that have occurred since the previous statement of purpose. During audit of the care files the Inspector noted evidence of comprehensive assessments of service users needs. Tracking from service user assessment, risk assessment, care planning and evaluation the Inspector noted clear evidence that the service can meet the assessed needs of the service users. Service user statement, and that of external professionals confirms that the service does meet service users needs. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 9 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The home reflects service users changing needs and personal goals in their individual plan of care. The home assists service users to make decisions about their lives. The home support service users to take reasonable risks is part of an everyday lifestyle. EVIDENCE: The Inspector noted evidence of the service user generated plan of care. This appears to have originated from service user assessment and the use of Brandon trusts own person centered planning documentation. The Inspector noted no undue restrictions on service users freedoms in these plans. The Inspector noted evidence that staff will assist service users in living an independent life; to the maximum they are able. The Inspector noted that the service could demonstrate how service users individual choices are made and respected. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 11 The Inspector audited service user risk assessments. These were comprehensive, up-to-date and addressed areas of potential risk on behalf of the service user. The Inspector noted that the home takes action to minimise risk where possible and practical. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 14, 15 The service supports service users with opportunities for personal development. The home helps service users exercise choice and control over their own lives. The home supports service users engaging in appropriate leisure activities. The home support service users to have appropriate personal and family relationships. EVIDENCE: The Inspector noted that service users are supported to maintain and develop independent living skills at the home. This may take the form of supported household chores, all day care activities inside or outside of the home. Should service users wish they may attend church or an appropriate religious activity. Service users are supported to integrate into the local community by staff. Staff encourage and support service users to use local shops, cinema of pubs or leisure centres, or even just go out through local drink at a cafe. The staff 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 13 team all day care support workers enables service users to access local leisure activities, and take part in group trips. Service users are supported to maintain links with family and friends outside of the service. Visitors are welcomed into the home within reasonable social hours. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 The home supports service users with personal care in a manner they prefer and require. The home supports service users meet their physical and emotional health needs. EVIDENCE: The home staff support service users with personal care where appropriate. This may vary from help getting dressed to prompting with teeth all the hygiene generally. Staff at the home encourage service users to choose their own styles of haircut and clothing. Staff at the home support service users with the health care needs. This could be support attending a GP, or support to access local National Health Service facilities such as a hospital or outpatient appointments. Staff will escort service users and the system as appropriate. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 15 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, neglect and self harm. EVIDENCE: The home provide training the staff to identify and know how to deal with abuse. The Brandon trust provides training on a regular basis. Any incidents of abuse at the home are recorded and reported to the appropriate body. Training is given to staff to understand the causes of violence and aggression, and to provide staff with the means to manage this. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 16 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, 30 The home provides a comfortable and safe environment. The home provides service users with bedrooms, which promote their independence. The home is clean and hygienic throughout. EVIDENCE: Severn Avenue is a pleasant domestic size building that is reasonably maintained and presentable for service users. The home is suitable through stated purpose, accessible to the service users safe and maintain sufficiently well to meet service users needs. The premises are generally bright cheerful and pleasant with good quality furnishings, fittings and fixtures. Service users are provided with the bedroom that is appropriate to their needs. The service users bedrooms during the time of inspection, but pleasant well decorated and personalised. Service users may lock their bedrooms if they wish. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 17 At the time of inspection, the premises were clean and hygienic throughout. The Inspector noted no offensive odours in the building. The home was subject to 2 requirements regarding the general environment. One are fire door into one of the service users bedrooms was not closing correctly, this needs to be remedied. The Inspector also noted the downstairs hall carpet needs to be replaced. Further details are in the requirements section. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 18 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, 34, 36 The homes staff have clear roles and responsibilities. The home provides sufficient staff to support service users effectively. Service users are protected by the homes recruitment policy and practices. Service users benefit from a well supported and supervised staff team. EVIDENCE: The Inspector noted that the home had clear job descriptions outlining staffs roles and responsibilities within the home. The staff job descriptions were linked to achieving service users goals as set out in each of service users plan. The Inspector noted after checking through the of duty rota that the home has sufficient staff on duty to meet the needs of the service users. The Inspector discussed staffing with the manager. The Inspector audited the homes recruitment record is. The Brandon trust holds recruitment files and the Inspector is unable to confirm from information presented to him that sufficient checks have been done. The Inspector does note however that the manager has gone to Brandon trust headquarters to check the details held by the trust. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 19 The Inspector audited staff supervision. The Inspector noted that staff supervision has been conducted insufficient frequency to meet national minimum standards. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 20 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): 38, 40, 41 The home has an ethos and leadership style that benefits service users. The home safeguards service users rights and best interests with its written policies and procedures. Service users have access to the records and information about them. EVIDENCE: Staff and service user feedback indicates that the general management style is one that is open, positive and inclusive of service users. The Inspector audited to of the homes policies at random. Policies sampled were up-to-date and have sufficient detail to meet national minimum standards. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 21 The Inspector audited records generally. The Inspector noted that records containing service user information are available to the service user should they wish, and are stored securely in accordance with the data protection act. 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 22 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 1 2 3 3 3 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 X 29 X 30 3 STAFFING Standard No Score 31 3 32 x 33 3 34 3 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 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x x 3 x 3 3 x x 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 23 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 YA24 Regulation 23 2 b Requirement The Inspector noted the fire door into one service users bedroom does not close properly. The fire door is located at the top of the stairs, as you enter the first bedroom on the l2 This must be remedied. The fire door must be able to close correctly. The downstairs all carpets proceeding along into the corridor must be replaced. 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. Timescale for action 08/02/06 1 3 YA24 YA1 23 2 b 41a 08/08/06 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI 46 Severn Avenue DS0000008130.V278080.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!