Inspection on 18/04/07 for Avalon

This inspection was carried out on 18th April 2007.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avalon 10/12/08

Avalon 24/01/06

Avalon 21/12/04

Avalon 05/07/04

Avalon 27/01/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Avalon 43 Woodfield Lane Ashtead Surrey KT21 2BT Lead Inspector Joseph Croft Unannounced Inspection 18th April 2007 10:00 Avalon DS0000013502.V333111.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 Avalon DS0000013502.V333111.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. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avalon Address 43 Woodfield Lane Ashtead Surrey KT21 2BT 01372 278039 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) www.together-uk.org Together Working for Wellbeing Mr Daniel Toby Osborne Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (3) Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 5 (five) persons between 21-65 years and up to 3 (three) people maybe over 65 years. 24th January 2006 Date of last inspection Brief Description of the Service: Avalon is a registered care home for people with mental health needs. Together Working For Wellbeing manages it in partnership with Richmond Churches Housing Trust. The property is located in a quiet residential area in Woodfield Lane, Ashtead and is close to public amenities. Buses run to nearby Epsom, Leatherhead and Guildford that has good shopping and sporting facilities. The property is a large, two storey, detached building and provides accommodation for eight service users. The house has a drive with private parking available and a large garden at the back of the property that is private and secluded. The home has a communal area, a conservatory, eight single bedrooms, adequate bathing and washing facilities, a laundry, a kitchen and dining area. The registered manager is Daniel Osborne. The weekly fees are £770. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 18th April 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took over five hours, commencing at 10:00 and concluding at 15:30. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with the manager and two members of staff on duty. The Inspector also had discussions with seven residents and he observed staff interaction with them. Feedback from residents was complimentary about the home and the care they receive from the staff. Both residents and staff were complimentary about the manager of the home. The pre-inspection questionnaire completed by the home has been used as a source of evidence in this report. Comment cards were sent to residents, their families and other associated professionals, which unfortunately have not been returned to the Commission For Social Care Inspection at the time of writing this report. The inspector would like to thank the manager, staff and residents for their cooperation during this visit. What the service does well: Assessment documentation is in place to ensure the individual needs of residents can be met. People who use the service have care plans and risk assessments in place, and are supported by staff to lead active lives. Residents are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. The storage, administration and recording of medication procedures protect the residents. Physical and health care is offered in such a way as to promote residents’ independence. The home has a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect residents. The home provides good communal and individual living space making it a safe and comfortable place to live. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents; people who use the service are protected by the organisations recruitment policy and procedures, and are safeguarded by good management of the home, and ensuring the health and safety of residents and staff is promoted. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Avalon DS0000013502.V333111.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 Avalon DS0000013502.V333111.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): Standards 1 and 2 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use services are provided with information about the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The manager showed the inspector a copy of the Service Users Guide that is entitled ‘Welcome to Avalon.’ This was a large document that contained information in regard to Avalon, however, this was not in an appropriate format for residents to easily read and understand. A good practice recommendation has been made that each resident should be offered a user friendly Service Users Guide which includes all as stated in regulation 5 of The Care Homes Regulations 2001 as amended. The home uses the ‘Together Working for Well Being’ Admissions Policy and Procedure that gives clear guidelines on the pre-admissions process to be followed for all prospective residents. The deputy manager informed the inspector that the admissions procedure includes obtaining an assessment of needs and introduction visits to the home. This provides prospective residents the opportunity to meet the staff, residents and view the bedroom they will use. As part of the case tracking process, the pre-admission assessment for two residents recently admitted to the home were viewed. The inspector was not Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 9 able to ascertain the views of one resident due to the severity of his mental illness, however, the second resident informed the inspector that they received information about the home and had a visit before moving in. Avalon DS0000013502.V333111.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): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place that ensures their needs are met, and are supported by staff to lead active lives. EVIDENCE: Two care files were sampled as part of the case tracking process. These provided evidence that care plans and risk assessments had been completed, and residents had signed them. Staff involve the residents in the planning of care that affects their lifestyle and quality of life. Care plans sampled included information in regard to physical health, personal care, social skills and leisure. Annual reviews had been conducted, and monthly reviews are undertaken with residents and their key workers. During discussions residents informed the Inspector they are aware of their care plans, know whom their key worker is, and that they have monthly meetings where they are included in the revision of their care plans. Key workers gave an accurate account of the care plans for residents who they key work with, and understand the importance of supporting residents to take control of their own lives. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 11 Residents informed the Inspector they are asked what they would like to do, where they want go, and make decisions about their lives that include activities, leisure and meals. Residents are consulted on a regular basis through residents and key worker meetings to ascertain their views of their care plans and the running of the home. The deputy manager stated that some residents require support when making decisions, and risk assessments for certain activities are in place. Residents have access to a local advocacy group who they can contact. A trainee counsellor is currently visiting the home every week and is available for one to one discussions with residents. Risk assessments were evidenced in the care plans sampled, and had been reviewed on a regular basis. Avalon DS0000013502.V333111.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): Standards 12, 13, 15, 16 and 17 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. EVIDENCE: Two residents undertake voluntary part time work, one with the organisation the other with a local club. Residents are encouraged and supported to be as independent as they are able. Activities undertaken include clubs, day centres, leisure activities, shopping, restaurants and household chores. During discussions residents informed the Inspector they enjoy the activities they do both in the home and at the day centres, and they can choose whether or not to partake in them. During discussions staff informed the Inspector that residents are able to make choices in regard to activities, and are supported as and when required. Records of activities undertaken by residents are maintained in daily records. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 13 The home holds summer and Christmas parties for residents, relatives and neighbours. Residents are supported to practice their religion if they wish to, and a church minister visits the home at least four times a year. Only one resident attends church on a regular basis. Staff support residents to maintain contact with their families and friends, and visitors are always welcomed at the home. Residents are encouraged and supported to make and maintain personal relationships, and staff offer information and advice in regard to relationships. One resident informed the inspector of a special boyfriend she had who sadly passed away recently. Residents are provided with information in regard to relationships. Residents undertake the daily routines in the house. These include shopping, cleaning and cooking duties. Residents informed the Inspector they take it in turns to cook the main meals for all residents and staff once a week. They stated they choose the menu, buy the food, and prepare and cook it. Residents were observed to have access to all communal parts of the home, which includes the lounge, kitchen/dining area, and a large garden. Staff informed the Inspector that they promote residents’ privacy and dignity through treating them as individuals, calling them by their preferred names, promoting their independence and knocking on bedroom doors. This was confirmed during discussions with residents and observations during the site visit. Staff were observed interacting with residents in a caring manner, and respecting residents needs to have time on their own. The routines, activities and plans are resident focused and can be changed to meet individuals changing needs, choices and wishes. The menus submitted to the Commission For Social Care Inspection with the pre-inspection questionnaire provided evidence that meals are balanced with meat, fish, pasta, salads and vegetables. Fresh fruit was observed to available to residents. It was observed that a healthy eating option was provided with each main meal. The home does not have a cook and staff support residents with the cooking duties. Training records evidenced staff had received training in regard to Food Hygiene. Staff informed the Inspector that special diets are catered for. Food was found to be appropriately stored in the kitchen area, and records of fridge/freezer and cooking temperatures were evidenced. During discussions staff and residents stated that the food is always good and balanced with meat and fresh vegetables. Avalon DS0000013502.V333111.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): Standards 18, 19 and 20 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s storage, administration and recording of medication procedures. Physical and health care is offered in such a way as to promote residents’ independence. EVIDENCE: During discussions staff stated that residents do not require support with their personal care. Key workers offer advice to residents in regard to personal hygiene. Residents are able to choose the time they go to bed and get up in the morning, the clothes they wish to wear and their hairstyles. This was confirmed during discussions with residents. Residents living at the home are that of white British origin. The deputy manager informed the Inspector that the home has a diverse staff team that includes Asians, South Americans and Africans. Care plans sampled evidenced residents are registered with the local GP practice, Dentist, Optician, Psychiatrist, and have access to all National Health Services. During discussions, residents informed the Inspector that they see the GP when they need to, and get their medication on time. Staff encourage residents to maintain their independence through a risk management approach. Residents are able to attend male and female health clubs if they Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 15 wish to. The staff informed the Inspector that any concern regarding residents’ health is referred to the GP. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for residents who were part of the case tracking process were accurately maintained. One resident currently self medicates and a risk assessment was in place and viewed by the inspector. Evidence of monthly review of this document was observed. The home follows the ‘Together Working for Well Being’ Medical Policy and Procedure. Evidence was seen that staff had attended training on the “Administration and Handling of Medication.” Avalon DS0000013502.V333111.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): Standards 22 and 23 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect residents. EVIDENCE: The home has a Complaints Policy and Procedure that includes time scales and the Commission For Social Care Inspection contact details. A copy of this is provided to each resident, and is made available to families and visitors to the home. During discussions residents informed the Inspector they would make complaints to the manager of the home. The complaints book was viewed and evidenced there had been no complaints made to the home. The Commission For Social Care Inspection has not received any complaints, concerns or allegations in regard to the care home. The home has a Protection of Vulnerable Adults Policy and Procedure that was reviewed in March 2006. Staff spoken to were able to give an accurate account of the procedures to be followed in regard to abuse and/or suspected abuse, and stated that the Surrey Multi- Agency procedures would be followed. Evidence was viewed that all but the most recently employed member of staff had received training in regard to Protection of Vulnerable Adults. The home has a copy of the Surrey Multi-Agency Procedures of February 2005 that is available for staff to read. Information provided in the pre-inspection questionnaire informs that the home has a Whistle Blowing Policy that was last reviewed in 2003, which staff were aware of. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 17 The deputy manager informed the Inspector that residents have his or her own bank accounts. Two members of staff and the resident sign the records of financial transactions, and monies are checked during each hand over period. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are provided with good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The accommodation consists of eight single bedrooms on two floors. Bedrooms and communal spaces were brightly decorated, and residents had their own personal possessions that included photographs, televisions and radios. The deputy manager informed the Inspector that bedrooms are redecorated before a new resident moves in. There are four bathrooms and four toilets; each has an anti-bacterial liquid soap dispenser. The Inspector was informed that work is due to commence on one bathroom to convert it into a walk-in shower. The lounge has been made a no smoking area, which was discussed and agreed with residents. There is a conservatory where smoking can take place, but encouragement is given for residents to smoke in the garden, weather permitting. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 19 The property has a large garden to the rear that is maintained by volunteers and residents who wish to undertake gardening work. There are plans to have a summerhouse built in the garden where various activities will take place. Residents informed the Inspector they like their bedrooms and the communal areas of the home. On the day of the site visit the home was very clean, tidy and free from offensive odours. The home employs one domestic staff that undertakes all cleaning duties. The home has an Infection Control Policy that was last reviewed in September 2005. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents; people who use the service are protected by the organisations recruitment policy and procedures. EVIDENCE: The staff team is made up of male and female staff. The duty rota viewed evidenced there is a minimum of two staff on each shift, and staff undertake sleep in duties on a rota basis. The manager informed the Inspector that relief staff employed by the organisation are used as and when the need arises. External agencies are not used. During discussions, staff and residents stated that in their opinion there were always sufficient staff on duty to meet the needs of residents. Information provided in the pre- inspection questionnaire informed that 10 of the staff employed at the home hold the minimum of an NVQ level two or above. The Deputy manager informed the Inspector that one member of staff is currently undertaking the NVQ level 3, and another two staff are considering taking this training. A good practice recommendation has been made that the Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 21 manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. Random sampling of recruitment files evidenced compliance with the regulation regarding employment of staff to work in care homes. Files sampled included application forms, two written references, Criminal Record Bureau and POVA first checks, and proof of identity. The home follows the organisations Recruitment Policy and Procedure that was reviewed in 2005. Information provided in the pre-inspection questionnaire and random sampling of training records evidenced that staff had received regular training in regard to meeting the needs of residents living at the home. Future training in regard to the Mental Health Capacity Bill has been arranged for the whole staff team to be undertaken in May 2007. The organisation has a commitment to ensure staff are appropriately trained, and has an annual Learning and Development Programme for all staff in their employment. Evidence of staff receiving induction in line with the Skills to Care council was viewed during the site visit. During discussions, staff informed the Inspector they regularly receive training throughout the year. Staff also informed the Inspector they have regular one to one formal supervision, records of which were viewed in staff files sampled. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are safeguarded by good management of the home, and ensuring the safety of residents and staff is promoted. EVIDENCE: The home has an experienced manager who has been working at the home since 2002. He holds the NVQ Level 4 and the Registered Manager Award, and has completed the A1 NVQ assessors training. The manager is aware of his overall responsibilities and has communicated these to the staff team. During discussions staff informed the Inspector that the manager has an open door style of management, is a good communicator, approachable and values each member of staff working at the home. The manager informed that he ensures his training in regard to management is kept up to date. Recent training undertaken includes Stress Management, Training the Trainer, Protection of Vulnerable Adults and Efficient Management Performance. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 23 The company undertakes quality assurance through Regulation 26 visits and annual surveys of residents, their families and other associated professionals. The manager informed the Inspector that the home had been sent the wrong summary of the last survey undertaken by the company and that he is currently addressing this issue. Reports of Regulation 26 visits are not being forwarded to the manager. Records viewed evidenced the last report was received in 2005. A requirement has been made in regard to this. Evidence that all staff receive regular mandatory training that includes infection control was provided to the Inspector. Information provided in the pre-inspection questionnaire returned to the Commission For Social Care Inspection evidence that health and safety records are appropriately maintained and up to date. During the site visit the following records were evidenced; fire drill, risk assessments and servicing of fire equipment, Control Of Substances Hazardous to Health (COSHH) assessments and individual risk assessments for residents. The deputy manager informed the Inspector that residents are supported to have certain responsibilities in regard to health and safety checks. Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA39 Regulation 26 (5) (b) Requirement Timescale for action 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations Resident should be offered a user friendly Service Users Guide which includes all as stated in regulation 5 of The Care Homes Regulations 2001 as amended. The manager should develop a plan of how the home can achieve 50 of staff holding the NVQ level 2 qualifications or above. 2. YA32 Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford, OX4 2SU 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 Avalon DS0000013502.V333111.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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