Inspection on 28/06/05 for Avis House

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 but made no statutory requirements on the home.

Other inspections for this house

Avis House 12/08/08

Avis House 17/08/06

Avis House 09/01/06

Avis House 19/10/04

Avis House 24/06/04

Avis House 13/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Avis House Old Fallings Lane Fallings Park Wolverhampton WV10 8DH Lead Inspector Joy Hoelzel Unannounced 28 June 2005 10:00 th 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 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 Stationary 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. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Avis House Address Old Fallings Lane, Fallings Park, Wolverhampton, WV10 8DH Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 866036 01902 866036 Alphonsus Homes Susan Richardson Care Home 6 Category(ies) of Learning Disability (6) registration, with number Physical Disability (6) of places Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) Learning Disability who may also have Physical Disability and under 65 years on admission. Date of last inspection 19.10.04 Brief Description of the Service: Avis House is a care home providing accommodation, personal and nursing care to six people with a learning disability. It is situated in the Low Hill area of Wolverhampton, close to local shops and amenities. The home is purpose built and provides six single bedrooms with lounge and dining areas. There is adequate parking at the front of the building with a large garden at the rear. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two and a half hours on Friday 29th July 2005 and is the first of the statutory inspections for 2005/06. Six people were resident at the home at the time of the inspection. A tour of the building took place, two care plans were examined together with supporting documents, discussions were held with one service user and members of staff. What the service does well: What has improved since the last inspection? Areas of the home have been redecorated, service users being fully involved in choosing the colour scheme and wallpaper for their bedrooms. The home and the primary care trust have been involved in piloting a scheme for healthcare screening for all people living at Avis House. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 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. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 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 standard(s) 2 Although no new service users have been admitted to the home recently, the home has an appropriate admissions policy in place should the need for it arise EVIDENCE: The registered manager stated that there have been no new admissions to the home since the previous inspection. An adequate procedure is in place for use for planned admissions. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 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 standard(s) 6,7,9 Staff highly respect service users’ rights and there is a constant monitoring and review process to ensure that their identified needs are being met and very individualised care given EVIDENCE: Two service users care plans were randomly selected and evidenced a full detailed plan of care. The plans are reviewed and audited by the manager on a monthly basis and whenever possible the service user and/or relative is involved. Each care plan is highly individualised to reflect the needs of each person. The plans evidenced that people have been consulted on the consent to medication administration, ability/ capacity to have a key to their bedroom and hobbies and interests. Risk assessments are detailed and include the action to be taken with instructions for staff to reduce the risk. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,13,16 The lifestyle of the service users living at this home is excellent and through a framework of activities they are supported with living a full, meaningful life. EVIDENCE: The manager stated that educational and occupational activities are not appropriate for the current service users group. The home operates a very active social activities programme based on the likes and preferences of the service users. A coordinator arranges and organises the activities, which are mainly community based. At the time of the inspection five service users were going to an afternoon tea dance with one service user staying at the home. The registered manager stated that the service user would decide the activity for the afternoon and that she looked forward to this ‘special time’ on the one to one basis. Other activities include greyhound racing, shopping trips, dances and going to the cinema to name but a few. Staff were observed to be assisting service users with all aspects of their daily lives, assisting with personal care and interacting well with lively discussions about the arrangements for afternoons planned tea dance. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 11 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 standard(s) 18,19,21 The personal and health needs of service users are very well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis EVIDENCE: The care plans indicated service users preferences in regard to the personal care that is required, with the key worker system ensuring the consistency and continuity of care for each service user. Details of the individuals’ likes and dislikes are clearly documented. Each individuals health care needs are fully met with the care plans evidencing regular contact with specialists e.g. opticians, wheelchair specialists, continence advisors etc. Health checks have been carried out by the PCT, the findings were sent to the service user with a follow up visit planned for six months time. It is commendable to see that service users and/or relatives have been consulted about their wishes in the event of becoming terminally ill and arrangements after death. The details are fully documented in the care plan. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 12 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 standard(s) 22 The home has procedures to deal with complaints or concerns. EVIDENCE: The registered manager informed of one complaint that has been received since the last inspection in October 2004. This is currently being investigated through the homes own procedures and has yet to reach a satisfactory conclusion. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 13 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 standard(s) 24,30 Avis House is purpose built to care for people with high support needs and thus offers a high standard of accommodation tailored to meet the needs of the service users living there. EVIDENCE: The home is a purpose built single storey building and is most suitable for the current service users group. All six bedrooms are single occupancy, domestic in character and highly individualised. One service user has recently had her bedroom redecorated and chose the wallpaper and colour scheme. The communal areas are homely with a ‘lived in’ impression. At the time of the inspection the fire alarm was activated as part of the weekly safety checks. The fire-resisting door in the main corridor did not close; the registered manager must ensure that an appropriate closure is fitted to ensure the door closes correctly. The requirement from the previous two inspections has yet to be fully complied with in respect to the installation of the sluicing disinfector for the safe disposal of bodily waste. This was discussed in depth with the registered manager. This requirement must now receive priority attention. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 14 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35 Service users are supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner EVIDENCE: Staffing numbers remain at the agreed levels with the registered manager and three care staff from 09:30-16:30, one registered nurse and two care staff from 16:30-22:00, one registered nurse and one care staff as waking night staff. Two staff personnel files were inspected and include the required information for the effective recruitment of staff. There is a stable regular staff team with reliable bank staff to cover for annual leave and sickness entitlements. The training and development plan for all staff indicates that the core topics and specialist subjects continue to be accessed. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 15 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39, The quality of care provided in the home is strongly influenced by the calibre of the registered manager. EVIDENCE: The registered manager is a first level nurse with the necessary skills and experience to successfully manage the home on a day-to-day basis. She is currently undertaking additional training on the Registered Managers Award, which is nearing completion. Staff were observed to have a good open relationship with the manager, lively discussions were held between them. The service user stated that she liked the time that she is able to spend with the manager. Quality assurance and monitoring systems are ongoing; the registered manager explained that questionnaires have been sent out to families, the information gathered from the feedback has yet to be audited. Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 16 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 4 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Avis House Score 3 4 x 4 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x x x E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 17 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 24 Regulation 13(4)(c ) Requirement An appropriate door closure must be fitted to the fire resisting door in the main corridor to ensure it closes when the fire alarm is activiated. A sluicing disinfector must be installed for the safe disposal of body waste and to decrease the risk of cross infection and contamination This is outstanding from the previous inspection and must be seen as a priority requirement Timescale for action With immediate effect With immediate effect 2. 30 13(3) 3. 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 Good Practice Recommendations Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 2nd Floor, St Davids Court Union Street Wolverhampton WV1 3JE 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 Avis House E56 000017179 Avis House v241620 UI 280605 Stage 4.doc Version 1.40 Page 19 - 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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