Inspection on 28/02/06 for Avalon

This inspection was carried out on 28th February 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avalon 29/12/08

Avalon 29/12/06

Avalon 31/10/05

Avalon 21/03/05

Avalon 30/11/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Avalon Longhouse Road Chadwell St Mary Grays Essex RM16 4QP Lead Inspector Sarah Buckle Unannounced Inspection 28th February 2006 10:00 Avalon DS0000015518.V266228.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 Avalon DS0000015518.V266228.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. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avalon Address Longhouse Road Chadwell St Mary Grays Essex RM16 4QP 01375 841402 01375 841402 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) Mosaic Essex Mrs Lai Heng Phillips Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Excluding any person who is liable to be detained under the provisions of the Mental Health Act 1983 31st October 2005 Date of last inspection Brief Description of the Service: Avalon is part of Mosaic Homes and it provides accommodation with nursing for eight adults with learning disabilities. The premises consist of two single storey developments, which have been converted to a single property. The property is situated in a residential area of Grays, within close proximity to local shops and bus routes. Access to train services for London and Southend are within approximately one mile of the home. Care provision within the home is overseen by nursing staff with learning disability qualifications and experience. The home operates a key worker and designated nurse system to facilitate continuity of care. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three hours. Opportunity was taken to examine records and policies, one care plan and staff supervision files. A tour of the building was undertaken and staff and service users were observed interacting within the home. During the course of the inspection the registered manager and a deputy manager were spoken with. What the service does well: What has improved since the last inspection? What they could do better: There are still some outstanding maintenance issues within the home. At the last inspection, re-decoration and repairs to draughty double-glazing were Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 6 stated as a requirement, however the timescale was not met, nor was the timescale set by the responsible individual on the action plan. One care plan sampled did not contain support plans or risk assessments in relation to some of the specific needs of the resident. Not all staff members had undertaken POVA training. Food opened and stored within the fridge was not labelled, dated or signed. 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 DS0000015518.V266228.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 Avalon DS0000015518.V266228.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): Not inspected. EVIDENCE: Not inspected. Avalon DS0000015518.V266228.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, 8 and 10 Individual care plans were adequate. Residents are encouraged to make choices and participate in aspects of life in the home. Confidentiality was handled appropriately. EVIDENCE: One care plan was sampled and this contained detailed and instructive support plans, which clearly identified the abilities of the resident and the areas in which he required support. The resident’s key worker reviewed the care plan on a four weekly basis. Risk assessments were completed in relation to moving and handling, medication and transportation using the house vehicle, however, there were no risk assessments or clear support plans regarding the resident’s epilepsy, or the management of pressure sores for which he was deemed high risk. The care plan did reflect the emphasis placed by the home on encouraging choice, decision-making and independence i.e. the support plan stated that the resident was able to choose his own clothes and that he was able to undress the top half of his body, but required support for his trousers and socks. The Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 10 care plan identified what the resident was able to undertake independently, and support was provided to fill in the gaps. Residents meetings were held regularly with decisions made about food, residents’ likes and dislikes and discussions regarding where the residents would like to go and what they would like to do i.e. one resident said that they would like to out shopping in the mini bus, another said he would like to go to a football match and another said that he would like a hand massage and to go to the library. The resident’s records were seen to be secure and stored in a cupboard within the office. Avalon DS0000015518.V266228.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): 15, 16 and 17 Avalon encourages family links and respects the rights and responsibilities of residents. The home offers a balanced healthy diet. EVIDENCE: The registered manager stated that one resident within the home has regular visits from his family. The deputy manager stated that the family visit every other day, visit the resident whilst he is out at day services and are involved in taking him to hospital appointments. The care plan sampled demonstrated family involvement. During the inspection, staff members were observed to interact with residents in a familiar and supportive manner. Residents were addressed by their preferred name and this was recorded within the care plan. One resident was out with a staff member completing the weekly house shopping for Bungalow A. The registered manager explained that one resident who partakes in day services has a position on reception and answers the phones at one centre, and is learning computer skills at another. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 12 The menu was examined. The home operates a four weekly rotation of menu system and the residents are offered a varied and balanced diet i.e. a choice of breakfast, with a cooked breakfast on Saturdays, soup or jacket potatoes for lunch, fish with broccoli and butter beans for dinner. The deputy manager explained that the home have recently sought advice from a dietician in relation to the meals that they offer. Avalon DS0000015518.V266228.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): 19 and 20 The physical and emotional needs of residents are adequately met. Medication is well managed. EVIDENCE: The care plan sampled outlined details of professional input as required i.e. the district nurse visited to change one resident’s catheter and a referral was made to a chiropodist. There was evidence of a monthly weight chart completed regularly and a Waterlow pressure sore risk assessment. The medication records were examined and although there was one omission, these were otherwise well managed, with a photograph of each resident on each Mar sheet and separate detailed PRN protocols for each resident and each medication. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 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 and 23 Resident’s views are listened to and acted on and they are, in the main part, protected from abuse and harm. EVIDENCE: The complaints procedure was displayed in the hallway in pictorial format. There have been no complaints since the last inspection. A resident had recently disclosed to a staff member an incident of concern and the staff member relayed this information to the registered manager, who in turn informed her line manager. Action has been taken in relation to this incident. The registered manager stated that she was unsure as to whether the incident had been reported to the appropriate social services department. The training file was examined and all but two members of the staff team had evidence of POVA training. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 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): 24 and 29 Avalon is in the main part, comfortable and homely. Specialist equipment is maintained. EVIDENCE: Avalon is comfortable and homely, however there are still some outstanding decoration and repair issues. Damage to the hallway caused by wheelchairs has still not been rectified, neither has the damage to the wall in the living room of Bungalow A. The deputy manager stated that a quote has been received from Glorcroft in relation to these issues. The draughty double gazing has not been repaired throughout the house. The registered manager stated that the windows in Bungalow A had been repaired, but not in Bungalow B. It was positive to note that the hoists within the home had been serviced on 20/12/2005. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 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): 33 and 36 The staff team within Avalon are effective, but the numbers are not currently sufficient. Supervision is well managed. EVIDENCE: The staff rotas were examined and demonstrated reasonable shift patterns, rest days and no excessively long hours. Avalon currently has one staff vacancy and one new staff member due to start employment. The registered manager stated that they are currently using bank and agency staff and that they have a core group of staff that are familiar with the residents and the home. She explained that four staff members work within the home to cover the early and late shifts and that there are two waking night staff. She stated that there are not currently enough staff members to allow spontaneity, as many of the residents have a high level of need and if one staff member goes out with a resident there are only three left to work with the remaining seven residents. She stated that this has an impact on what the staff team are able to do with the residents. Staff meetings were held on a regular basis and the recorded minutes were seen. Three supervision files were examined and all had evidence of recorded formal supervision on a regular basis. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 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): 37, 39 and 42 The home is well managed. The health and safety of residents is, in the main part, protected. EVIDENCE: The registered manager at Avalon completed her NVQ4 on 11/03/2005. The home is well organised, and Mosaic Homes’ policies and procedures are implemented. The registered manager stated that quality assurance is currently undertaken by Mosaic Homes head office. She explained that this consists of relatives meetings, which are held twice a year. It was positive to note that fire extinguishers had been serviced on 25/11/2005. Mandatory training in moving and handling, first aid, fire safety and food hygiene had been undertaken by two staff members whose training files were looked at in detail. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 18 Water temperatures were checked and recorded on a weekly basis, however, it was noted during the inspection that some items of food including cooked meats and preserves had been opened and stored within the fridge, without being labelled, dated and signed. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Avalon Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000015518.V266228.R01.S.doc Version 5.0 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. Standard YA6 Regulation 15(1) Requirement The registered person must ensure that the service users’ plan demonstrates how the resident’s health and welfare needs are to be met. Timescale for action 14/04/06 2. YA23 13(6) This is in relation to one care plan not containing support plans or risk assessments in relation to epilepsy or pressure sores. The registered person must 14/04/06 make arrangements to prevent residents being placed at risk of harm. This is in relation to POVA training not having been undertaken by all staff members. The registered person must 01/05/06 ensure that the premises are kept in a good state of repair and that all parts of the home are reasonably decorated. This is in relation to wheelchair damage in the hallway of the home and in the lounge area of bungalow A; it is also in relation to the double-glazing within the home, which is draughty and 3. YA24 23(2)(b) and (d) Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 21 needs to be repaired. This is a repeat requirement with the 31/12/05 timescale not met and Avalon’s action plan completion date of 14/02/06 not met either. The registered person must ensure that there are sufficient numbers of staff working at the home as appropriate to meet the health and welfare of residents. This is in relation to residents not being able to go out as much as they would like owing to their level of need and available staff members. The registered person must ensure that a report is supplied to the Commission in respect of any review of quality of care. This is in relation to the quality assurance reviews’ undertaken by Mosaic Homes and to this information not being made available to the Commission. The registered person must ensure that any unnecessary risks to the health or safety of residents are identified and eliminated. This is in relation to food being opened and kept in the fridge without being labelled. 4. YA33 18(1)(a) 01/05/06 5. YA39 24(2) 01/05/06 6. YA42 13(4)(c) 14/04/06 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 Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 22 1. YA17 Label food as opened with date. Avalon DS0000015518.V266228.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 DS0000015518.V266228.R01.S.doc Version 5.0 Page 24 - 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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