Inspection on 24/01/06 for Avalon

This inspection was carried out on 24th January 2006.

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

Other inspections for this house

Avalon 10/12/08

Avalon 18/04/07

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 Kenneth Dunn Unannounced Inspection 24th January 2006 10:00 Avalon DS0000013502.V276109.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 Avalon DS0000013502.V276109.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. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 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.V276109.R01.S.doc Version 5.1 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. 18th July 2005 Date of last inspection Brief Description of the Service: Avalon is a registered care home for people with mental health needs. It is managed by Together Working For Wellbeing 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. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was the home’s second inspection for the year 2005/2006. This was an unannounced visit, which meant that staff and residents were unaware that it was due to happen. The inspector was able to spend some time with residents that were at home. Some of the residents gave permission for the inspector to access their rooms and spoke about their day and life in the home. All of the residents who spoke with the inspector seemed happy living at Avalon. The inspector spent part of their visit in discussion with the duty manager looking at cares plans, staff files, resident’s records and reports. The premises have been developed and improved in recent years and this work was ongoing. What the service does well: What has improved since the last inspection? Documentation at the home has been improved. Care plans are now regularly reviewed, dated and signed by all parties involved in the review process. The resulting documents ensure service users’ needs are more clearly identified and met. All requirements placed upon the service during the previous inspection report have been actioned. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 6 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. Avalon DS0000013502.V276109.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 Avalon DS0000013502.V276109.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): The service continues to meet the core standard please refer to the previous inspection report dated 18th of July 2005. EVIDENCE: Avalon DS0000013502.V276109.R01.S.doc Version 5.1 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 systems for Residents consultation are good, with evidence that indicates that their views are both sought and acted upon. Service users are assisted and supported by staff to make decisions that affect them directly or indirectly. EVIDENCE: Each resident had an individualised care plan; they are now all regularly reviewed in line with a requirement from the previous inspection report. The inspector was informed by the duty manager that the system in operation now employed at the home requires the members of staff conducting the review, the individual service users and any other relevant party to sign and date the revised documents. This is to ensure that the care plans in use are current and offer the most accurate information to the person implementing it. The care plans audited during the inspection all contained in-depth risk assessments on all aspects of the service users daily lives such as, road safety, fire procedures, kitchen duties and lone travel. The inspector was informed that the daily lives of the service users are only impeded if there is a risk identified associated to that activity. If the risk is sufficiently high enough staff will take intervention action to minimise the potential of the service users coming to harm, this is fully detailed on the assessment forms and discussed with the individual concerned. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 10 Within the house the residents are encouraged to actively participate in the day-to-day operations of the home, they play a led role in fire safety checks household chores and shopping. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 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, and 16 The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that service users’ rights are respected. EVIDENCE: All service users have individual care plans. The plans reviewed by the inspector gave clear details of the individuals service users stated like and dislikes enabling staff to offer the most appropriate assistance to each resident. Staff enable and work with service users to plan and follow activities and pursuits based on the care plan information. Service users are also offered the opportunity to try activities that they have not tried before this is planned and actioned at the speed dictated by the person involved. The daily routines in the house reflects the requirement to promote independence, individual choice and freedom of movement the service users were enabled to make choices of what to do, when to do it and more importantly the right to refuse if they so wish. Staff support service users to maintain family links and friendships inside and outside the home, this may involve family members or friends being invited to Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 12 participate in planned activities, meals, events or enabling the service user to visit the family home. There are no restrictions to visiting and service users can see visitors in the privacy of their own rooms if they wish. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 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 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: All service users are registered with the local GP and have access to all NHS healthcare facilities as required. Health records were seen as part of the inspection process. There is a good medication policy in place and a robust set of procedure governing the administration of medication. At the time of this inspection four service users had been risk assessed as suitable to take responsibilities for their own medication. This process was reviewed and the systems in place appeared to safeguard the service users. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 14 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 All required policies and procedures are in place to ensure that service users feel their views will be listened too. The home operates a robust policy ensuring the service users are protected from all forms of abuse. EVIDENCE: The service has updated the policy on the protection of the service users and in line with a requirement from the previous inspection report it now contains a section detailing the category of professional abuse. The inspector was informed that one of the main roles of the key worker system employed at the home was to enable the service users to identify what is an appropriate relationship and what may be considered abusive. The key workers are also responsible for ensuring that the service users have the ability and confidence to complain or the query actions taken against them. The inspector was given details of an incident that occurred to one service users outside of the home by a member of the public. The service user felt confident enough to approach the manager and explain what had happened to him in the local community with the knowledge that what had accrued was inappropriate and would in all probability result in further investigation. The support offered to the service user was well documented and enabled the resident to participate in the process of interviews and support. The manager and the staff group immediately implemented the services Vulnerable Adult Procedures in an effort to safe guard the service users and to ensure the correct authorities became involved and took appropriate action. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 15 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): All assessed standards now comply with the National Minimum Standards. EVIDENCE: Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff individual training files sampled evidenced that staff receive regular updated training in First Aid, Health and Safety, Fire Safety, Food Hygiene and Handling, Protection of Vulnerable Adults, Moving and Handling and COSHH. During discussions staff stated they attend regular mandatory training days. The record reviewed did not offer a clear and reflective view of the training undertaken by the staff. The inspector identified several areas where there were gaps in the recording of completed training events. The development of a robust procedure for the recording of all training g must be developed to ensure that all staff receive the necessary training they require to work within the service. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 17 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): 39, 40 & 42 Avalon is a well-run service the policies and procedures in place are designed to safeguard and protect the service users. EVIDENCE: The organisation operates an annual quality assurance (QA) survey, which is designed to promote the person completing the form to reflect on the service they receive and to freely respond to the questions. The most recent QA was completed in November 2005, the results have been analysed by the organisation who in turn feed the results back to the home. However the organisation has retained the completed forms and therefore the results could not be audited during this inspection. The manager has conducted a review of the policies and procedures and inline with a requirement from the previous inspection report these documents are now signed, dated, reviewed and amended. Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 18 Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X 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 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 1 3 X 3 X Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 20 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 2 Standard YA35 YA39 Regulation 18(1) 24 Requirement Timescale for action 20/02/06 The manager must ensure that all staff training is completed and appropriately recorded. The registered provider must 20/02/06 ensure that all documentation with direct correlation to the service is available on site for future inspection. 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 Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Avalon DS0000013502.V276109.R01.S.doc Version 5.1 Page 22 - 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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