Inspection on 31/10/05 for Avalon

This inspection was carried out on 31st October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 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 28/02/06

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 31st October 2005 12.45 Avalon DS0000015518.V261743.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.V261743.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.V261743.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.V261743.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 21st March 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 of 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.V261743.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, care plans and staff files. A tour of the building was undertaken and service users were observed in the lounge. During the course of the inspection the registered manager was spoken with in depth and two members of staff were spoken with briefly. What the service does well: What has improved since the last inspection? What they could do better: The home does not have a robust system in place for the servicing of fire equipment and hoists. This could affect the health and safety of service users and staff. Since the closure of a number of day centres within the area, the home should ensure that all residents are engaged in meaningful and stimulating occupation and are able to maintain social and community links. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 6 The premises at Avalon should be regularly maintained to ensure that they are comfortable and homely for the service users. 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.V261743.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.V261743.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Appropriate information regarding Avalon is available to service users prior to their admittance into the home. There is a thorough pre-admission assessment and a gradual transition process into the home wherever possible. Written contracts are of a good standard. EVIDENCE: The Statement of Purpose and Service User Guide have not been changed since the last inspection. The pre-admission assessment is completed using a Mosaic Homes form entitled ‘Resident’s Assessment of Abilities’. The registered manager undertakes the assessment with the service user. This form covers activities, service user abilities and details of the support required. Two care plans were sampled and in each of these, the pre-admission assessment was completed thoroughly. In one of the care plans sampled there was also pre-admission material from Thurrock Council. Prospective service users have the opportunity to visit the home prior to admittance, and there is a three-month trial period in place. The registered manager explained that the admission process within the home aims to make the transition as gradual as possible. She said that one service user was admitted in an emergency, and that he visited the home in the morning with a social worker, and then moved into the home in the afternoon subject to the trial period. Another service user was able to visit the home on a number of Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 9 separate occasions, including visiting for meal times and finally staying over night prior to his admission. Two service user contracts were seen. These were thorough in their detail and included an assessment to state that the service user was not able to sign the agreement. A pictorial form of the contract was available within the service user guide. It was positive to note that the registered manager is planning to make a video of the information within the contract for the service users. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 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 and 9 Individual care plans were comprehensive, personal to the individual service user and regularly reviewed. Service user risk assessments were thorough. EVIDENCE: Two care plans were sampled and both of these had detailed support plans, which clearly identified the needs of the service user. Short and long term goals and the means of achieving these were present, as was the name of the staff member making the assessment and the date. Thorough details of the support needed were included in a step-by-step fashion and these were written from the service users point of view. The care plans are reviewed regularly on a four weekly basis. The service users’ key worker completes the review. Twice yearly there is an Individual Programme Plan Review. Relatives are sent an invitation to attend this review, and have the opportunity to forward any comments they would like to make if they are unable to attend. One comment seen written by a service users’ mother states “I have no complaints. He is in good hands”. It was positive to note that in both care plans the IPP review had been completed in advance of next months meeting and stored in the file. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 11 Risk assessments are contained within the care plans and are amended when there is a change of need. i.e. one service user suffered a fall and has been advised to lose weight and not to mobilise without support. These factors have been included in his risk assessment. It was positive to note a relative/next of kin contact sheet, which informs staff when to make contact if a specific incident occurs and a comprehensive Personal Profile, which detailed the name and contact details of the service users’ advocate, consultant, social worker, dentist, chiropodist and district nurse. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 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): 11,12,13 and 14 The home strives to enable service users to engage in stimulating and meaningful occupations and leisure however this could be developed further. EVIDENCE: During the inspection, three service users were out doing their Christmas shopping at Lakeside. The registered manager explained that some service users used to go to day centres but that these services have recently closed due to funding. She said that the Community Access Team has also ceased to exist. One service user now attends Thurrock College two days each week. Some service users go to the local library and visit the local shops. They have attended a Halloween party and a physiotherapist comes to the home every Thursday. Two service users visit the physiotherapist for Hydrotherapy on a Friday morning. The registered manager explained that Mosaic Homes run a Monday club, which enables service users to go bowling or to the pub and a Tuesday club for social activities, such as visiting Watt Tyler Park as well as a party night every three months organised by managers. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 and 21 Personal support needs are clearly documented in the service users individual care plans. Medication at the home is well managed. Ageing, illness and death are dealt with sensitively, and the service users wishes are well recorded. EVIDENCE: It was noted within one care plan that the personal care needs of the service user were detailed and clear and appropriately met by staff. The medication records were inspected. Protocols were seen to be in place for the use of PRN medication. The qualified staff undertake Boots medication training each year. Avalon runs in-house medication training by qualified staff, for support workers. There were no omissions apparent on the MAR sheets. In relation to the sensitive issues of death and dying, the home has a form, which they encourage relatives to fill out on the service users behalf. The registered manager said that bereavement counselling is available for staff and service users. Avalon DS0000015518.V261743.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): Not inspected. EVIDENCE: Not inspected. The complaints procedure was displayed in the home in both written and pictorial format. Avalon DS0000015518.V261743.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, 25, 26, 27, 28, 29 and 30 Avalon is in the main part, comfortable and homely. The service users bedrooms are individualised. There are some outstanding maintenance issues. EVIDENCE: The home appeared comfortable. A radiator that was noted to be broken at the last inspection has been repaired. Damage to the hallway caused by wheelchairs has not been rectified. The draughty double-glazing that was an issue at the last inspection has not been attended to. No date is currently set for this these repairs to be completed. The repair and redecoration of the damage caused by wheelchairs and the draughty double-glazing will make Avalon more homely and comfortable for the service users. The home is two bungalows joined together, and there are therefore two kitchens, two dining rooms and two lounges. Some damage was noted to the wall in the living room of Bungalow A. The registered manager said that she would request that a dado rail be fitted when it is redecorated. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 16 Three service users bedrooms were seen. These were all individual and personalised according to the taste of the service user. Each room had its own sink. Two bathrooms and two shower rooms were seen; these were large and clean and had the appropriate aids and equipment within them. However, it was noted that the hoist had not been serviced since 04/11/2004. The service users’ safety is at risk if hoists are not appropriately serviced. The dining rooms and the lounges were furnished in an appropriate manner. Three service users were seen watching the television in the lounge of Bungalow B. A member of staff was with them and they appeared to be content. The home was seen to be clean and tidy and there were no odours. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35 The home has clearly defined staff roles. There is comprehensive training within the home and a robust recruitment procedure. EVIDENCE: A sample of staff files were seen and these had a copy of the appropriate job description enclosed within them. One staff file was seen to include evidence that a one-day induction had been completed. The registered manager stated that she would train a new staff member for six months with supervision every four weeks, or more if required. One staff file inspected contained a three-week induction programme and an induction record. There was also evidence of mandatory training i.e. manual handling, person-centred planning, fire training, POVA. The service users within the home should therefore be assured of having their individual needs met by a competent staff team. The registered manager stated that one member of staff had recently completed her NVQ 3 and that four other members of staff are working towards this qualification. It was positive to note that some specialist training in Diabetes and Parkinson’s disease has been introduced, which will further enable the staff team to meet the needs of the service users. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 18 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): 40 and 42 The policies and procedures within the home were appropriate. The health and safety protection for service users and staff was not adequate. EVIDENCE: Mosaic Homes’ policies and procedures are in place within Avalon. These were seen to be kept so as to be accessible to staff and had a review date in 2006. Avalon conducts a monthly fire drill. The names of the staff involved and the time of the drill were recorded. Fire training was carried out in 2004 and 2005 and the most recent member of staff completed the training in September 2005. A record was seen demonstrating the weekly check of fire doors, fire exits and emergency lighting however, the fire extinguishers within the home had not been checked since September 2004. Fire equipment maintenance is necessary to ensure the protection of both service users and staff. Avalon DS0000015518.V261743.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 3 3 3 3 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Avalon Score 3 X 3 3 Standard No 37 38 39 40 41 42 43 Score X X X 3 X 2 X DS0000015518.V261743.R01.S.doc Version 5.0 Page 20 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 YA24 Regulation 23(2)(b) and (d) Requirement The home 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 the wheelchair damage in the hallway of the home and in the lounge area of bungalow A; it is also in relation to the doubleglazing within the home, which is draughty and needs to be repaired. The home must ensure that equipment provided for use by service users of staff is maintained in good working order. Timescale for action 31/12/05 2. YA29 23(2)(c) 01/12/05 3. YA42 This is in relation to the hoisting equipment within the home that is overdue to be serviced. 23(4)(c)(iv) The home must ensure that 01/12/05 adequate arrangements are made for the maintenance of all fire equipment. This is in relation to fire extinguishers that have not been checked since 09/2004. Avalon DS0000015518.V261743.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations It would be good practice for the home to replace activities for service users who no longer attend day services or have the provision of input from the Community Access Team. 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