Inspection on 09/01/06 for Avis House

This inspection was carried out on 9th January 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avis House 12/08/08

Avis House 17/08/06

Avis House 28/06/05

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 West Midlands WV10 8DH Lead Inspector Joy Hoelzel Unannounced Inspection 9th January 2006 11:20 Avis House DS0000017179.V275773.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 Avis House DS0000017179.V275773.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. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Avis House Address Old Fallings Lane Fallings Park Wolverhampton West Midlands WV10 8DH 01902 866036 01902 866036 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) Alphonsus Homes Mrs Susan Richardson Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Learning Disability who may also have Physical Disability and under 65 years on admission 28th June 2005 Date of last inspection 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 separate lounge and dining areas. There is adequate parking at the front of the building with a large garden at the rear. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over two hours on Monday 9th January 2006 and is the second of the two statutory inspections for 2005/06. Six people live at the home, and at the time of the inspection one registered nurse and three support workers were on the premises A tour of the building took place, one care plan was examined together with supporting documents, discussions were held with one service user and the staff members. What the service does well: What has improved since the last inspection? Redecoration of areas within the home continues with service users being fully involved in the choice of colour schemes. The recommendations from the recent fire officers inspection have been complied with. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Avis House DS0000017179.V275773.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 Avis House DS0000017179.V275773.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): EVIDENCE: This set of standards was not inspected on this occasion. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA 6,9 The service user plans are comprehensive and updated at appropriate intervals ensuring that individuals’ needs are met EVIDENCE: The care plans continue to be highly individualised to the needs of each person at the home. The acting manager has only been in post since October 2005 and stated that all plans are being thoroughly assessed and care reviews for each person are being organised. Further assessments of need will be implemented to include a falls risk and tissue viability assessments. Staff were observed to be providing personal care with dignity and privacy. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 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 the following standard(s): YA15, 16,17 Service users are supported to lead full and active lives. EVIDENCE: The families and friends of the service users are encouraged and actively welcomed into the home. The acting manager stated that most service users have regular visitors but described the difficulties at times for the people who do not have families. Weekly coffee mornings continue to be arranged to offer the additional opportunity for visitors to the home. At the time of the inspection one service user, with support from staff, was busy making cakes for the afternoon tea. Other service users were engaged in playing board games or watching television. As usual the home was lively with staff and service users interacting with each other well. The support staff prepare all meals, which are based on a rotational menu suitable to the current service user group, with cheese and potato pie being prepared for the midday meal. The food cupboards were well stocked with supplies, the acting manager undertakes the shopping for the home each week. Fresh fruit and vegetables are available to service users each day. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 11 Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 12 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): YA 20 The home has a safe system of handling, storing and managing medication EVIDENCE: The home operates a twenty-eight day regime for medication administration using a monitored dose (blister pack) system with the additional use of some bottles and boxes. The medication is stored in locked trolleys and cupboards in a locked room. Policies and procedures are in place for a safe system to be maintained, stock medication was at a minimum and the Medication Administration Record charts appeared to be fully completed. The care plan contained a copy of the consent to medication administration by the home staff; an advocate on behalf of the service user signed this. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 13 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): YA22, 23 Minor amendments to the complaints procedure will ensure that service users and visitors are provided with the relevant contact details. EVIDENCE: The complaints procedure is displayed at the entrance of the home. The procedure must be updated to include the current details of how to contact Commission for Social Care Inspection should a complainant wish to do so. No complaints have been received at the home or Commission for Social Care Inspection since the last inspection. The whistle blowing policy is available to staff for reference and is included in the induction programme. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 14 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): The home continues to provide a high quality, comfortable and safe environment for those in residence. The provision of specialised equipment would further enhance the working conditions for the staff. EVIDENCE: The home continues to be well maintained to a high standard. Redecoration of the bedrooms continues with the full involvement of the service user in choosing the colour scheme. The fire door in the main corridor has been attended to and now closes correctly. Staff must be commended for maintaining the very high standards of cleanliness observed around the home. The requirement from the previous three inspections has yet to be fully complied with in respect to the installation of the sluicing disinfector for the safe disposal of bodily waste. Freestanding commodes were observed in the majority of the bedrooms for use during the night. The potential risk of cross infections and the possible contamination of splashes to staff was discussed in depth with the acting manager. This requirement must now receive priority attention. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 15 Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA32, 33,35,36 There is a stable staff group working positively and enthusiastically to provide the service users with a quality of life that meets their individual requirements. EVIDENCE: A learning disability trained nurse supported with first level nurses and care staff manages the home. The staff and acting manager demonstrated a good knowledge and understanding of the needs of the current service user group. Each service user is offered very individual care; staff have developed good alternative ways of communicating when verbalising is difficult. Monthly staff meetings take place, which are recorded and actioned, the last one being held 22nd December 2005. Formal staff supervision is ongoing at least six times a year and training and development requirements have been identified with a plan implemented for the coming year. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): YA 37, 42,43 Management arrangements are satisfactory, staff are clear about their roles and responsibilities. Regular safety and maintenance checks continue to promote and safeguard the health, safety and welfare of service users and staff. EVIDENCE: An acting manager has been recruited in October 2005, with the registered manager moving to another position within the company. The acting manager is a learning disability nurse with the skills and experience to manager the home on a day-to-day basis. As she was a previous employee at the home, she was able to demonstrate a good in depth knowledge of the current service user group together with the additional responsibilities of becoming the registered manager. She is currently rostered for all clinical duties; supernumery time is not yet available. The formal application for the position of registered manager is to be forwarded to Commission for Social Care Inspection shortly for the process to commence. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 18 Maintenance records evidence that the required checks are being carried out, to include water temperatures, fire alarms, fridge and freezer temperatures etc. The employer’s liability certificate displayed at the entrance of the home is out of date with the expiry date being 02/12/05. Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 x 3 X X X X 3 2 Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 20 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 22(7) Requirement The complaint procedure must include the current contact details of Commission for Social Care Inspection. 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 three previous inspections and must be seen as a priority requirement. Timescale of August 2005 not met. The registered person must ensure that the appropriate insurance cover is in place and the current certificate is displayed. Timescale for action 31/01/06 2. YA30 13(3) 31/01/06 3 YA43 25(2)(e) 31/01/06 Avis House DS0000017179.V275773.R01.S.doc Version 5.1 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. Refer to Standard Good Practice Recommendations Avis House DS0000017179.V275773.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Wolverhampton Area Office 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 DS0000017179.V275773.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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