Inspection on 29/12/06 for Avalon

This inspection was carried out on 29th December 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avalon 29/12/08

Avalon 28/02/06

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 29 December 2006 10:00 th Avalon DS0000015518.V291851.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 DS0000015518.V291851.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 DS0000015518.V291851.R01.S.doc Version 5.1 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.V291851.R01.S.doc Version 5.1 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 28th February 2006 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. The fees within the home are on average £1050.00 per week. This information was provided on 29th December 2006. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine key inspection of the service provided by Avalon. The inspection was announced as the home’s staff recruitment files were requested to be available. This was so that the Family Mosaic corporate recruitment procedure could be examined and was not a reflection of a specific concern regarding Avalon. The inspection included a site visit, which lasted two and a half hours. Pre inspection information was completed by the registered manager and returned to the Commission within a specified time frame. A tour of the premises was undertaken and staff and residents were observed interacting within the home. Opportunity was taken to examine records, policies and relevant documents. During the source of the inspection the registered manager was spoken with in depth, a resident was also spoken with, as was one staff member. Information regarding the service provided at the home was also obtained from four relatives, a GP and a health and social care professional. What the service does well: What has improved since the last inspection? Since the last inspection a revised and updated statement of purpose and service user guide have been implemented. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 6 Care plans are comprehensive and contain detailed information regarding the support needs and abilities of residents. 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 DS0000015518.V291851.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 DS0000015518.V291851.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process at Avalon is well managed. The needs of residents are met by the home. EVIDENCE: The registered manager revised the service user guide and the homes’ statement of purpose and the Commission received copies of these in August 2006. The documents are well presented, contain all of the specified information and the service use guide makes good use of photographs to illustrate the text. There have been no new admissions since the last inspection. The newest resident within the home was an emergency admission. They arrived at the home with relatives and had a three-month trial period. The registered manager carried out an initial assessment on the day of admission. This was seen during the inspection and was a thorough document. This has been updated as changes have become apparent. There was a reassessment date of 02/09/06 on the document. After three months a review was held with the resident social worker, where the resident made the decision to remain at Avalon, as they liked it. In discussion with the resident he stated that he liked it at Avalon and wanted to stay there. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 9 The initial assessment states the abilities of the resident as well as any support needs and is clearly focussed on maintaining independence. For example, it states that the resident is “Able to choose what (the resident) likes to wear and can co-ordinate (the resident’s) clothes”, and “(The resident) is able to wash (their) own upper body” and “requires two staff to hoist (the resident) on and off shower chair”. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans seen were of a good standard, reflecting the changing needs of residents. Risk assessments adequately demonstrated that residents are supported to take appropriate risks. EVIDENCE: One care plan was sampled during the inspection and this was a comprehensive document, with support plans in place for all identified areas. These clearly outlined the preferences of the resident, for example, containing details of the packed lunch to be prepared when they visit day services, and what this should consist of. Risk assessments were in place regarding such areas as, moving and handling, medication, the risk of pressure sores and the management plan in place to reduce this. Health related details were thoroughly recorded, including GP and district nurse visits, yearly health monitoring, blood tests and monthly weight charts. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 11 As the resident has epilepsy there was also an ‘epilepsy monitoring form’ detailing time, date and duration of seizure. This also included the type of seizure, any injuries sustained, length of recovery time and mental state after the seizure. Weekly opportunities were recorded and these included assisting within the home, karaoke and puzzles, attending a birthday party, listening to music and going out with family. The care plan was regularly reviewed. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to partake in appropriate activities, to access the community and to maintain family relationships. The home offers a balanced, healthy diet. EVIDENCE: One resident was case tracked during the course of this inspection and it was clear that they were able to partake in appropriate activities. The individual has placements at both the Progression Centre and at the Ashleigh Centre, however, has chosen not to attend for the last two months. This decision has been honoured by the home and the placement has been kept open for him. The individual helps to do the weekly shopping and is given an amount of money and a list of items to purchase. The resident was spoken with and stated that he enjoyed doing this. A job has also been arranged for him on a two hourly basis at Mosaic head office. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 13 Family are encouraged to visit the home and where possible residents are taken to see their relatives. One resident has family who live close to the home and they visit him often. His mother visited him at Avalon on Christmas Day, and he went to visit her on Boxing Day. The registered manager stated that she had taken another resident home to see their mother on 28th December. One resident also has a mobile phone and his family are able to call him regularly. The menu was examined. Avalon operates a four weekly rotation of menu system and the residents are offered a varied and balanced diet. One resident spoken with said they enjoyed the food at the home, and that they were involved in some preparation, such as peeling potatoes. They also said that they like to dry up. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care in their preferred manner; their physical and emotional needs are met. Medication is well managed. EVIDENCE: One care plan was sampled during the inspection and this clearly demonstrated that the abilities of the resident were considered to be as important as their support needs. The areas that the resident could accomplish were clear and detailed as were the areas where support was required. One resident spoken with stated that he is very happy at the home and that all of the staff help him in any way they can. He stated that he can talk to any of the staff members and that they are supportive. The registered manager stated that only qualified members of staff administer medication. The medication file was examined and this was comprehensive. A photograph of individual residents was incorporated into their medication administration record. There were PRN medication records and the reason for administration, with the date and time given and a signature. PRN protocols Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 15 were also contained within the file giving clear and detailed explanations of the reasons for use and the criteria to be met prior to administration. The instructions regarding how to administer these medications were of an excellent standard. There was one omission seen within the medication file and two medication profiles had been handwritten but not signed or witnessed. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents are listened to and they are adequately protected from harm and abuse. EVIDENCE: The have been no complaints since the last inspection. The home’s complaints procedure is displayed in pictorial format in the hallway. There is a comments/compliments/complaints book and this was examined during the inspection. Four compliments had been received since the last inspection. One stated “Have been visiting Avalon for five to six years in my professional field and always find staff helpful and communication between staff and residents very good. Residents are always treated with respect and dignity”. A district nurse had signed this entry. Avalon holds regular service user meetings, usually once each month. These are minuted. The minutes were examined during the inspection and demonstrated that residents have an impact on the running of the home by making choices in relation to menu’s and activities. The training log was examined. All staff members have undertaken manual handling training, and most have completed POVA training. One staff member Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 17 spoken with was clearly aware of the procedure to follow if she suspected an incident of abuse. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment at Avalon is safe and homely, however there are still outstanding maintenance issues. The home is suitably clean and hygienic. EVIDENCE: A tour of the premises was undertaken. All of the bedrooms seen were tidy and comfortable and had been personalised according to the taste of the individual. For example one bedroom was adorned with West Ham shirts, posters etc. The damage to the hallway caused by wheelchairs had not been attended to, however, all of the draughty double-glazing had been repaired. A letter was seen during the inspection stating that all of the outstanding refurbishment required at the home would be completed on the next financial year. The home was clean and tidy. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 19 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): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff members at Avalon are competent. The home’s recruitment practice is robust. Staff training is well managed. EVIDENCE: There are currently sixteen members of staff working at Avalon. The home has twenty-four hour qualified cover, four staff on duty each morning and evening and two waking night staff members. The registered manager has one supernumery day. Four staff recruitment files were examined, and all of these contained the required information. One bank staff file was also examined and this contained all of the required information. When agency staff are used, their information goes to Family Mosaic human resources department. Training within the home is on going. All of the staff members have received manual handling training. Two staff members currently have NVQ 3, two further staff members are registered to begin NVQ 2 training in January 2007. The registered manager has completed the NVQ4 as has one of the deputy managers and a second deputy manager is due to start the NVQ 4 in January Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 20 2007. It was noted that not all members of staff had completed POVA training. One staff member spoken with stated that she enjoyed working at Avalon. She said that she had been at the home for less than a year and had completed training in breakaway techniques, POVA, manual handling and fire training. She said that she had six weeks of induction training prior to starting properly and that she is supervised on a monthly basis. She said that she feels supported by all of the staff and that they work together as a team. The staff member stated that there are always four members of staff on duty during the morning and afternoon shifts. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Avalon is a well run home. Quality assurance is managed at corporate level; however, resident’s views do inform the running of the home. The health and welfare of residents is adequately protected. EVIDENCE: The registered manager at Avalon is qualified and competent. She was talked with at length during the inspection and her outlook was positive and proactive. One resident spoken with stated that he liked the manager very much. One member of staff spoken with stated that they found the manager to be approachable and supportive. Quality assurance within the home is handled at a corporate level. A variety of health and safety certificates were seen during the inspection and all of these were in date. Fire drill records were examined and these were held Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 22 on a monthly basis. Fire doors, emergency lighting and fire exit checks were recorded as being carried out weekly. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 23 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 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 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 24 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 YA23 Regulation 13(6) Requirement The registered person must 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. This is a repeat requirement with the previous timescale 14/14/06 not met. The registered person must 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 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. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 25 Timescale for action 14/04/07 2. YA24 23(2)(b) and (d) 01/05/07 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. 2. Refer to Standard YA20 YA39 Good Practice Recommendations It is good practice to sign and countersign handwritten medication profiles, to reduce the risk of errors. Quality assurance is managed at Family Mosaic corporate level, however, findings from this research relating to Avalon must be formulated into a report and forwarded to the Commission on an annual basis. Avalon DS0000015518.V291851.R01.S.doc Version 5.1 Page 26 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.V291851.R01.S.doc Version 5.1 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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