Inspection on 13/10/05 for 63a Victoria Avenue

This inspection was carried out on 13th October 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63a Victoria Avenue 17/08/07

63a Victoria Avenue 27/04/06

63a Victoria Avenue 21/04/05

63a Victoria Avenue 16/11/04

63a Victoria Avenue 19/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Victoria Avenue (63a) 63a Victoria Avenue Wallington Surrey SM6 7JP Lead Inspector Deborah Yapicioz Unannounced Inspection 13th October 2005 DS0000007210.V254848.R01.S.doc Version 5.0 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 DS0000007210.V254848.R01.S.doc Version 5.0 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. DS0000007210.V254848.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria Avenue (63a) Address 63a Victoria Avenue Wallington Surrey SM6 7JP 020 8669 4559 020 8669 4559 manager.victoriaavenue@careuk.com 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) Care Solutions Limited Ms Karen Campbell Care Home 7 Category(ies) of Learning disability (0), Physical disability (0) registration, with number of places DS0000007210.V254848.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 7 people with learning disabilities and physical disabilities. Date of last inspection Brief Description of the Service: 63a Victoria Avenue is owned managed and staffed by Care U.K. The home is registered to provide residential care for up to seven adults with learning and physical disabilities. At the moment there are six service users at the home with one vacancy. The current service users have complex needs. The premises is a modern purpose built two-storey house set back in a quite residential road in Wallington. The home was built approx four years ago. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The home is in the process of changing one of the rooms on the first floor to a sensory room. The home is homely, bright and clean. The furniture is domestic, flame retardant, and of good quality. The home has a lift and is fully accessible to the service users. The home has parking to the front and a pleasant garden at the rear of the home which the service users spend time in during the summer months. DS0000007210.V254848.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place on 13th October 20005, just before lunchtime. The home was inspected under the National Minimum Standards Care Homes for Younger Adults. The inspection was spent having a discussion with Karen Campbell the home manager, looking at records, observations of staff and service users, talking to staff and a tour of the premises. What the service does well: What has improved since the last inspection? What they could do better: The majority of service users at the home have had an annual holiday. The home manager explained that for some service users it is not appropriate for them to go away for a week on holiday. When this is the case the service users DS0000007210.V254848.R01.S.doc Version 5.0 Page 6 should have at least five individual days outing to places that it is of interest to them. It was noted at the last inspection that the vehicle used by the home was not appropriate for the service users at the home The homes management team need to reassess the viability of the vehicle used by the service users, as they have to make multiple journeys to get all service users to their destinations. The original group of service users to the home were admitted on a block contract, which was a common practise at the time. Service users should now have an individual contract. 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. DS0000007210.V254848.R01.S.doc Version 5.0 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 DS0000007210.V254848.R01.S.doc Version 5.0 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): 1,2,5 The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. Contracts between the home and many of the service users are still not in place, this could potentially reduce the rights of these residents. EVIDENCE: The home has a statement of purpose and a service users guide. The home has a procedure for introducing service users to a new residential placement, which includes the homes, own assessment process and introductory visits. New Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. Any new service users to the home will only be considered once compatibility with the current service users is established. The original group of service users to the home were admitted on a block contract. This was a common practise at the time and the company is working with the service users care manager to provide individual contracts. The service users who have recently moved to the home have individual contracts. DS0000007210.V254848.R01.S.doc Version 5.0 Page 9 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 service users have comprehensive individual care plans with detailed information on their needs and personal goals. Individual care plans include consultation with service users and are regularly updated by the key-worker to reflect current needs. EVIDENCE: Each of the service users has an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The home has recently introduced a pictorial Person Centred Plan format to the home, which is an individual tailored care plan. The care plans are on the service users file and is a record of their aims and goals as well as their achievements. The key worker of each service user completes monthly reports, which form a useful tool in monitoring changing needs, and ensuring goal/targets can be met. The home manager completes a regular check of the service users files to ensure they are kept up to date. DS0000007210.V254848.R01.S.doc Version 5.0 Page 10 The service users at the home have limited communication skills and the home manager stated that the staff team have built up a good relationship with the residents and use that knowledge to advocate on their behalf. The home manager explained that the home has introduced more communication aids since the last inspection. The service users have a six monthly in house review and an annual multidisciplinary meeting. The home operates a risk management system and individual assessments are on service users files. Copies of individual risk assessments are kept on the service users file. There are also risk assessments relating to the environment and staff under the health and safety at work act. Risk assessments are reviewed regularly. DS0000007210.V254848.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The service users at the home are offered the opportunity to engage in age appropriate activities with an emphasis on using community based facilities although this is limited by the type of vehicle used by the home. The daily routines and house rules promote residents’ rights and encourage independence as far as possible. EVIDENCE: It is part of the role of the staff team to encourage service users at the home to maintain and develop independent living skills. The service users have a weekly activity timetable and details of the service users weekly commitments are also recorded on service users files. There is a strong emphasis on service users using the community facilities. It was one of the aims of the home manager to increase the range of outside activities accessed by the service users at the home. Records at the home show that service users have been on various outings including restaurants, cinema, bowling, Madame Tussauds and the London Eye. The home also provides in house activities such as aromatherapy. The home manager is in the process of changing one of the upstairs room to a sensory room. DS0000007210.V254848.R01.S.doc Version 5.0 Page 12 It was noted at the last inspection that the vehicle used by the home was not appropriate for the service users The home has five service users that use a wheelchair, unfortunately the homes current transport will only accommodate two wheelchair users. This means the home has to make multiple trips to get all the service users to their destination instead of just one. This is not a good` use of staff or service users time. The registered provider must ensure that the home has a more appropriate form of transport suitable for the needs of the service users. Three of the service users have been to Euro Disney on holiday not all service users at the home has had an annual holiday. The home manager must ensure all service users have an annual holiday where this may not be appropriate for the service users then the service users should have at least five individual days outing to places that it is of interest to them. A record of the visits/ outings should be kept on the service users files DS0000007210.V254848.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical and emotional health needs are detailed in personal plans to offer consistent care in this area. Residents’ medication is well managed to ensure good health. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. All medication records were complete at the time of the inspection. The service users need varying degrees of assistance with their personal care or at mealtimes. The service users all need assistance with their personal care. The service users have all had manual handling assessments and risk assessments. There are hoists, overhead tracking, specialist baths and handrails in place to assist with manual handling. The staff at Victoria Avenue have all had instructions on manual handling, which forms part of the induction and is followed up by mandatory training. The level of support a service user needs would be detailed at review meetings and their preferred routines are set out in their individual Plan. All service users are registered with a local General Practitioner. The staff team at the home monitor the health of each of the service users and would ensure they receive any treatment needed. Healthcare summery s DS0000007210.V254848.R01.S.doc Version 5.0 Page 14 detailing appointments are kept on file and up dated by the person’s key workers. Incident forms are completed following any accidents. DS0000007210.V254848.R01.S.doc Version 5.0 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): 22,23 There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The complaints procedure was clear and contained all of the elements required to meet standard 22 including a minimum response time of less than 28 days. The complaints procedure is also in picture format. The home has a copy of the local authority Adult Protection Policy on site and staff receives training on these issues. DS0000007210.V254848.R01.S.doc Version 5.0 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): 24,25,30 The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: 63a Victoria Avenue is a modern purpose built two-storey house set back in a quite residential road in Wallington. It is situated between Carshalton and Wallington town centres and is also close to local shops and amenities. There is a large communal lounge on the ground floor as well as a spacious kitchen/dining room. The home has been opened for approx five years. The home has a lift and is fully accessible to the service users. There is also a pleasant garden at the rear of the home which the service users spend time in during the summer months. The general décor of the house has been improved since the last inspection. The lounge and communal areas including the hallways have been redecorated. Many of the service users bedrooms have also been redecorated. The service users artwork is on display in the lounge and corridors. DS0000007210.V254848.R01.S.doc Version 5.0 Page 17 The premises were generally bright, airy and clean on the day of the unannounced inspection. The home has a heath and safety policy in place which includes specific policies covering the disposal of clinical waste, control of infection, use of cleaning materials, storage and preparation of food, use of protective clothing and dealing with spillages. There is a Control of Substances Hazardous to Health cupboard. Health and safety law posters were on display in the home. The homes washing machine was capable of thoroughly cleaning foul laundry at appropriate temperatures (minimum of 65 Degrees Celsius). The laundry room was positioned so that laundry does not need to be carried through the kitchen DS0000007210.V254848.R01.S.doc Version 5.0 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): 31,32,34,35 The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: The staff job descriptions were comprehensive in there content and linked to achieving service users goals, as set out in their individual care plans. The home offers training opportunities to staff at all levels within the home. New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. The staff team have also been able to access a number of other training courses during the past year, including L.A.D.A.F., Values training, Care Planning, Communication, fire training, Vulnerable Adults, food hygiene, first aid, medication, health and safety and moving and handling. The home has regular staff meetings Criminal Records Checks are completed before a new member of staff can begin work. DS0000007210.V254848.R01.S.doc Version 5.0 Page 19 The home manager has continued to incorporate more information sharing and basic value training to the staff meetings, which she feels has raised awareness of service users rights amongst the team and introduced a more service users, led approach. There are four staff members on duty during the day plus the manager. DS0000007210.V254848.R01.S.doc Version 5.0 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): 37,39,42 The home management appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: Ms Karen Campbell took over the management of 63A Victoria Ave in September 2004. She is in the process of completing a National Vocational Qualification course level four. Ms Campbell is now registered with the Commission for Social Care Inspection as the manager of the home Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service users case files, medication records and so forth. DS0000007210.V254848.R01.S.doc Version 5.0 Page 21 A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Coloured chopping boards and knives were seen in the kitchen. All staff must attend training relating to health and safety issues including fire safety and medication training. A record of training attended is kept on staff files. A representative of the registered provider visits the home regularly and copies of the visit report are sent to the Commission for Social Care Inspection Corydon office. DS0000007210.V254848.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000007210.V254848.R01.S.doc Version 5.0 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 51. (C) Requirement The registered person must ensure the homes new contracts/statement of terms and conditions of occupancy agreed between the home and the service users specify the rooms to be occupied; fees charged, what they cover, and the cost of extras not covered by the basis cost of the placement. (Unmet from the 2004 inspection) The registered provider must ensure the home has an appropriate form of transport suitable for the needs of the service users. Timescale for action 01/02/06 2. YA13 12 (1)(b) 16 (2)(m) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA14 Good Practice Recommendations The home manger must ensure that all service users have DS0000007210.V254848.R01.S.doc Version 5.0 Page 24 an annual holiday. For those service users who do not go away on an annual holiday then at least five “days out” to places that are of particular interest to them should be planned. A record of the activities should be kept on their file. DS0000007210.V254848.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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