Inspection on 12/09/06 for Avondale

This inspection was carried out on 12th September 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avondale 22/09/05

Avondale 16/05/05

Avondale 06/09/04

Avondale 15/04/04

Avondale 15/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Avondale 62 Stratford Road Salisbury Wiltshire SP1 3JN Lead Inspector Roy Gregory Key Unannounced Inspection 12th September & 25th October 2006 10:20 Avondale DS0000015889.V309772.R01.S.doc Version 5.2 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 Avondale DS0000015889.V309772.R01.S.doc Version 5.2 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. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Address 62 Stratford Road Salisbury Wiltshire SP1 3JN 01722 331312 01722 416041 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) Turning Point Limited Mr Roger Mouncher Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of service users to be accommodated at any time must not exceed 14. Two beds are to be used for respite only. Staffing for the two respite beds is to be arranged separately to the main staffing for the home and is dependent upon the assessed needs of individuals receiving this service. Staffing for service users receiving respite care is therefore additional to the staffing levels below. 4. The home must comply with the Residential Forum Guidance on staffing levels for care homes for 12 service users with high needs. Staffing levels must reflect the numbers and needs of service users in the home at any one time. A minimum of 5 staff must be on duty in the home when all service users are present. 5. Due to the complex needs of the service users cared for in the home there must at all times be a member of staff who has received appropriate training in the following: PEG feeds, suctioning, administration of rectal stesolid, medication administration and safe use of oxygen. Date of last inspection 2nd May 2006 (Random inspection) Brief Description of the Service: Originally a health service establishment, the home dates from the 1980s. It is now operated by Turning Point, a voluntary organisation that also provides other care services for this client group within the city of Salisbury. The home has two floors connected by passenger lift and provides single room accommodation to 12 service users. Two other registered places were until recently used as a respite resource, staffed separately from the home itself, but this provision has ceased and been de-registered. There is direct access from the downstairs sitting room to the large garden, which is mainly to lawn or patio. Also downstairs are the dining room and kitchen. The latter is not suited to access by service users. There are sitting areas around the home, including upstairs. Specialist bathroom facilities and other aids are provided. Adjacent to the home is a day resource operated by Turning Point, which is extensively used by home residents. Avondale is situated in an attractive residential area a short drive both from Salisbury city centre, where there are good public transport connections, and from open countryside. There is car parking on site, and bus stops are adjacent. The standard weekly fee is £1075. This does not cover items such as toiletries and periodicals. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit for this inspection took place between 10:20 a.m. and 6:20 p.m. on Tuesday 12th September 2006. The acting manager, Lea Wintle, was available throughout the day, whilst the registered manager, Roger Mouncher, attended at the home between 1:15 p.m. and 2:00 p.m.. The inspector, Roy Gregory, met with most of the service users during the day, including sharing lunch with service users and staff in the dining room. Interactions between staff and service users were observed in the communal areas. Additionally there were conversations with support staff on duty at the time of the visit. The inspector read three support plans in detail to compare observations of care with written records and plans. Other records consulted included those relevant to staff training and supervision, health care and health and safety. All communal areas of the building were visited and two bedrooms were seen. A further visit was made by arrangement on 25th October 2006, specifically to check recruitment records in respect of staff who had been recruited since the previous inspection. This was because these records had been retained centrally by the provider organisation and so were not available for unannounced inspection. Survey questionnaires were sent to close relatives of all service users and seven were received back. There was also a response from the GP who has medical responsibility for all the service users. The judgements contained in this report have been made from evidence gathered during the inspection, which included the visit to the service and taking into account the views and experiences of people using the service. What the service does well: Avondale provides care and support to people with a wide range of quite complex needs. In support of health needs, there are a number of protocols to be followed for some individuals to ensure rapid access to professional health care when the need arises. Staff are familiar with these, as with the other contents of support plans. Notifications to the Commission, daily recording, and observations by the inspector, confirmed that care is provided in a very individual way, in line with written guidance. Service users’ relatives responding to the survey indicated high levels of satisfaction with the nature of care, and the quality of established staff. One wrote additionally: “X is so happy and staff caring and helpful”. The inspector noted that, alongside the support staff, kitchen and administrative staff were also knowledgeable about the service users and displayed excellent working relationships with them. Since the previous inspection there had been an admission to the home, and preparations for the admission of another service user were well advanced. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 6 The quality of assessment and preparative work was excellent, paving the way for smooth transitions with both service users and staff able to begin placements with sound knowledge and expectations. Provision of meals and organisation of mealtimes were both of a high standard, support staff providing appropriate assistance and communication. Standards of hygiene throughout the home were high. What has improved since the last inspection? What they could do better: Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 7 Relatives responding to the pre-inspection survey were almost unanimous in seeing the home as sometimes under-staffed, or at least over-reliant on agency staffing and on existing staff working double shifts. Staff retention and recruitment have clearly been constant concerns for the home, with measures in place to address them. Probably related to this background, the majority of support staff do not hold NVQs in care. A high level of recognised qualification is a means by which a service can demonstrate that staff have the professional skills and values expected by the people in their care, and by their supporters. There is a requirement for a plan by which the proportion of qualified staff can be increased to more than 50 of the support staff. The pharmacist inspector found service users were protected by the home’s procedures for handling medication, but has made requirements to improve safe storage of medicines, and of oxygen. 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. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 8 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 Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 9 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): 2, 3 & 4 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Assessment procedures are in place, which take into account the wishes of prospective residents and make use of other professionals’ assessments. New service users are assisted to have contact with the home before admission and can therefore be confident in the care that will be provided. EVIDENCE: At the time of inspection visit there had been one new admission since previous inspection. On record was a new Community Care Assessment from their care manager, with a positive recommendation for placement at Avondale. There was evidence that the service user’s family were very much in favour of the placement owing to the success of previous respite stays. There was also evidence of the involvement of a local advocacy service, to help ensure the placement was in line with the service user’s needs and wishes. Home staff had completed an assessment to confirm the home could meet the person’s needs. To assist with this assessment, they had obtained pictorial handling guidance from an occupational therapist, and handwritten care advice from the family. It was possible to track the development of care plans and risk assessments from the information received prior to admission. A relative of this service user expressed total satisfaction with the admission process and the subsequent care provided. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 10 Registration of the service has been varied by the Commission to permit admission of a service user aged under 18 years. This followed inter-agency liaison, resulting in agreement that Avondale would be the appropriate service for the person concerned. Copies of care plans had been obtained from the person’s current placement as well as their social worker. During the inspector’s second visit to the service, an allocated member of staff returned from a morning spent working with the prospective service user, in their current placement and together with staff who knew their care needs. Avondale’s assessment was completed and had enabled preparation of care plans prior to the person moving in. The prospective user had visited the service, as had their nearest relative. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 11 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): 6-9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Support plans link clearly to risk assessments and to the inputs of external professionals. Residents are enabled to receive and give information about how the service is provided, and to exercise choices. EVIDENCE: Care plans examined followed a consistent pattern, with information about basic preferred routines easily accessible to staff. There was plentiful evidence of active review and, unlike on previous visits, folders had been de-cluttered. Staff demonstrated familiarity with the content of care plans. For one person whose care and records were looked at in detail, the inspector saw various staff carrying out care tasks in accordance with the person’s care plans. This included initiating and maintaining communication, and assistance to eating. All care plans seen were clear, and were linked as necessary to risk assessments or to guidance from external professionals such as dietician or physiotherapist. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 12 Documentation, and discussions with staff, identified that there was a wideranging knowledge of peoples’ personal preferences, whilst person centred planning had helped identify some individual wishes. There was an enabling approach to risk assessment, the process being used to facilitate safe, resourced access to community facilities such as swimming pools and transport. Almost all respondents to the survey of family members viewed their relatives as able to exercise choice over their daily routines. Lea Wintle described attempts to increase service user direct involvement in how the home operates by way of evening resident meetings as unsuccessful. Accordingly, there was a new initiative to hold meetings on Saturday afternoons, when it was anticipated attendance would be easier and visitors may be interested to join in. The inspector recommended borrowing from good practice seen at a sister home. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 13 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The nature of working relationships between service users and staff, mean that residents have access to planned and spontaneous activities that fit their individual wishes and needs. These provide for access to the wider community and maintenance of significant relationships. Good quality meals are served, taking account of individual needs. EVIDENCE: Permanent staff were divided into four groups (not reflected in how rotas were worked), each of which shared key working responsibilities for three service users. Associated tasks included making arrangements for holidays and for redecoration of rooms. Much community access work was undertaken by Turning Point outreach workers, but home staff said they were more involved than previously in such work themselves as staffing numbers had risen. During this visit, for example, two service users went out with two members of staff to have coffee at a supermarket, and to choose a selection of foods for use in sandwiches at the weekend. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 14 Within the home, service users were seen being supported to enjoy individual interests. One was assisted to use his hi-fi for music of his choice. Another was provided with pens and paper to write and draw, and received ongoing interest. There was encouragement to assist with simple tasks, and equally, recognition when people preferred to opt out or have time on their own. The home has extensive experience of “person centred planning” as a means of helping service users and their supporters to identify and achieve goals. The local advocacy service confirmed they had given active support to this process for people who had no family support available. During a lapse in provision of an external lead to person centred planning, staff had received training in a “person centred approach” to care, and there was an emphasis on planning how time could be best used for individuals. A person who had worked many years at Avondale considered changes over time to have benefited service users, as staff had more time and encouragement to get to know and work with them. There was photographic evidence of a range of “special” and “everyday” activities, including community access. A strong feature of the care approach in the home was effective communication with individuals, including some use of signing. Some service users had regular visits from family members. One relative routinely joined meals. Private space could be easily arranged. Staff were aware of close friendships between service users and assisted to sustain them. They were also skilled at creating opportunities for service users to join conversations if they wished. Staff used photographs to help one service user to recognise and recall events with members of their family. A photo board on the dining room wall was in use to assist all service users to know which staff were on duty. Staff kept up contact with service users when engaged on tasks such as writing records or getting supplies, and invited service user participation in some tasks. Where individual service users made use of outreach services or sessions at the adjacent day service, care records included evidence of liaison with staff in those services. Home staff were well aware of what service users did elsewhere, and dovetailed their care accordingly. Snack and meal times were easy-going. Staff joined service users at the table and gave discrete assistance where necessary, in line with care plan guidance. The home has the benefit of a chef, who has a natural rapport with service users, as well as producing high quality meals with much individual attention. Service users were able to exercise choice, and it was evident that mealtimes were enjoyed. There was support to individuals to manage tasks that might have been challenging without support, such as pouring drinks and clearing away, thus promoting inclusion and achievement. During the football World Cup season in summer, 2006, the home had a series of barbecue meals relating to different countries in the competition. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff offer personal support that matches service users’ needs and recorded preferences. Healthcare needs are recorded and their management includes use of external consultation and guidance in order to identify and meet needs. Service users are protected by the home’s procedures for handling medication, however some storage issues need to be resolved. EVIDENCE: Care records, and notifications to the Commission, showed adherence to the protocols in place for some of the service users who have relatively high needs, associated with specific conditions. There had been recent liaison with the GP about renewing these protocols. For one service user, a meeting was to be held at the hospital to ensure their needs were met in the best way by joint working, when their short-term admissions occurred. For the same person, care plans in respect of procedures associated with specific conditions and needs were linked to risk assessments and to the medications protocol – and were counter-signed by the GP and community nurse. Nutritional guidelines had been signed as updated in June 2006, and there were contact details for the person’s dietician. Further notes showed active liaison with the community nursing service, and with physiotherapy and wheelchair services. All staff Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 16 spoken to were aware of the person’s most recent change of medication regime, and the reasons for this. For a person diagnosed with dementia, staff were knowledgeable about issues of emotion and perception highlighted in the initial assessment. Care records showed alertness to risk factors, such as indicators of possible chest infection, and medical attention was procured promptly in response to concerns. The pharmacist inspector carried out an inspection of medications procedures on 21st September 2006 and reports as follows: The home is supported by a local GP and pharmacist, and policies and procedures are available to all staff. No residents are currently able to selfmedicate. Inspection of the records relating to medication showed that an appropriate audit trail for drugs received into the home is maintained. The printed medication administration records are completed when the drugs are administered. This was seen to be individual, taking account of residents’ needs. Security of the drugs is compromised because the key to the clinic room is available to all other staff and could be used by visitors. Fridge temperatures must be monitored. Individual protocols are followed for the treatment of epilepsy and other conditions; however, the emergency use of Oxygen should be reviewed. Safe storage of oxygen must also be considered particularly with regard to fire safety. Homely medicines are in use in the home, but guidelines for individual service users should be reviewed to ensure that the medicines are suitable for their use. An individual support plan about medication use explained the reasons why support was necessary, and recognised the individual’s right to refuse medication. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There are a number of safeguards built into individual support plans and service policies and procedures to keep service users safe, backed by relevant training for staff. Procedures are in place for the receipt and investigation of complaints and concerns. EVIDENCE: The home had received no complaints since previous inspection, whereas there were two compliments on record. As part of a large national organisation, the provision for receipt and handling of complaints is corporate and details are readily available to supporters. Management were pro-active in seeking resolution of difficulties experienced by service users in accessing hospital services, by using health service complaints procedures and the advocacy service. A member of staff had been suspended pending investigation of alleged improper conduct, which had been appropriately referred to inter-agency vulnerable adults procedures. This had demonstrated effectiveness of the company’s whistle-blowing procedure. Staff received training in abuse awareness and physical intervention, and received guidance on individual service user mental health needs from a community nurse. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 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, 25 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users benefit from private and communal spaces of good dimensions and homely appearance, but compromised by safety limitations on access to outside spaces, and use of some internal spaces for storage. Standards of hygiene are high. EVIDENCE: There had been some changes of individuals’ bedrooms since the previous inspection. In each case, advantages of a move had been identified, including health advantages, for example by moving to the ground floor. Supporters of service users had made requests for such moves. However, documentation could be improved, to show clearly how such decisions are arrived at, and how far the service user’s own views are canvassed. The environment as a whole was homely and welcoming, offering choice of location for service users along with good visibility for staff. Storage of equipment, such as hoists, is not good and encroaches on communal space. Uneven paving outside represented a compromise to safe access to the grounds. This had been recognised within the home, with safety measures in Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 19 place, but the planned rectifying of the problem must be prioritised to permit safe access for summer 2007. Standards of cleaning were very high throughout the home. The dining room, including furniture, was being kept clean by night staff, as were wheelchairs. The staff training schedule included provision for infection control training. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 20 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 - 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The staff group is diverse and highly committed to the care task, supported by good practice in recruitment and supervision. This results in good quality working relationships for service users, but staff retainment issues have entailed over-reliance on agency workers and staff working additional shifts. The level of qualification among support staff is low. EVIDENCE: Rotas showed general compliance with the home’s condition of registration that there must be five support staff on duty when all service users are at home. Over preceding months, this had entailed regular use of agency staff. It was envisaged this reliance would continue until recently recruited staff were able to start, as there had been further loss of staff, mostly for individual career move reasons. Lea Wintle said efforts were made to secure the services of consistent agency staff, but the record for the previous three months showed a total of 44 different agency staff had been used. It was the perception of almost all family members responding to the inspection survey, that there were not always sufficient staff on duty, and that agency use or staff working double shifts were not a satisfactory way to address the issue. Changes in internal and company management of staffing issues could be seen to have brought some advantages for more consistent staffing of rotas. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 21 Staff meetings were being held monthly. Minutes showed that a spread of operational and care issues were covered, including recently a reiteration of dress code. Team co-ordinators had a plan for ensuring formal supervision of all staff was kept up. Examples of supervision records showed this was a meaningful exercise, with a further supervision date always set. Training records and plans showed use of LDAF training and the arrangements made to ensure all staff receive training to enable them to work with individual healthrelated protocols. All but one of the team co-ordinators had achieved NVQ level 3, but NVQ achievement among support staff fell short of 50 . At the random inspection visit in April, 2006, a requirement was made that recruitment records must be maintained in such a way as to demonstrate that safe recruitment, in line with regulations, could be demonstrated. At the first of these inspection visits, it was found that these records were not being held on site, but at other offices of the organisation. Roger Mouncher undertook to obtain the necessary records for inspection, hence the second visit being made on 25th October, when they had been made available. Records for five newly appointed staff were checked. All contained the necessary information to demonstrate compliance with regulations, including having two references and criminal records disclosures. From 1st November 2006, the Commission has agreed to the central keeping of recruitment records by Turning Point, with arrangements for accessing these, but it will be in the interests of the individual establishment to keep copies of application forms and references to assist supervision, appraisal and disciplinary processes. A newly appointed member of staff confirmed he had had to await clearance by way of checks before being able to commence working in the home. He was supernumerary to the rota and shadowing other staff. He had received an induction pack on the day of starting duties. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 22 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Appropriate provision has been made for continuing efficient management to allow for the registered manager’s involvement in the service’s future development plans. The assessed needs and views of service users and their supporters are obtained to inform development of the service. There are good in-house and organisational arrangements for upholding health and safety. EVIDENCE: By agreement with the Commission, Roger Mouncher has been spending considerable time off-site in order to progress plans for development of the service, which currently is not financially viable. In his absence, team coordinator Lea Wintle has been “acting up” as day-to-day manager, with daily support from Roger Mouncher and evident support from the organisation’s area office. There was a written plan to confirm Lea Wintle’s and Roger Mouncher’s respective areas of responsibility. Other team co-ordinators had delegated areas of responsibility, such as medications and health & safety, as well as Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 23 giving a lead to care practice. All team co-ordinators had attended Turning Point management training events, which they experienced as motivating, and there was evidence of initiative and pro-active work in a number of areas. The company had instituted a system of “peer inspections”, adding an extra level of oversight to promote quality assurance, in a more thorough way than previous registered provider visits. Roger Mouncher said service users’ relatives had been contacted directly about Turning Point’s plans to develop how services may be provided in future to the users of Avondale. To uphold health & safety standards, the company requires submission by the home of a quarterly “compliance certificate”, which was an effective audit tool. The most recent had led to an action plan, which was being addressed, for example all risk assessments were in process of review. Staff immunisation records were being updated. Staff received repeated training in basic food handling, manual handling and health & safety. Whilst landlord guidance was awaited about legionella testing, all water outlets were being flushed weekly to avoid risk of creating conditions for bacterial growth. The requirement remains, however, to obtain certification in this matter, the inspector accepting that the service manager has pursued the matter with the landlords. Regular fire precautions testing was recorded, and staff had received fire training from an external consultant. This was about to be repeated to ensure inclusion of all new staff. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 24 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 3 3 3 4 4 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 2 X 3 X 3 X X 3 X Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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. 2. Standard YA20 YA20 Regulation 13(2) 13(2) Requirement Fridges used for the storage of medication must be monitored for suitable temperature control. Storage of medicines must be under separate lock, the keys of which are held safely and only available to trained staff. Suitable signage must be used in the home where oxygen is stored to show the fire risk. The outside patio area must be made safe for access by all service users. There must be a plan for ensuring that at least 50 of support staff achieve recognised qualifications. The provider must obtain and produce certification that the building is free of legionella bacteria. Timescale for action 01/12/06 01/12/06 3. 4. 5. YA20 YA24 YA32 YA35 13(2) 23 (2)(o) 18 (1) (a),(c)(ii) 13 (4)(c) 01/12/06 28/02/07 28/02/07 6. YA30 28/02/07 Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 26 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 YA8 YA25 Good Practice Recommendations Examine ways of increasing service user participation and feedback in residents’ meetings or by other means. When a service user occupies a different bedroom, the reasons should be fully documented and signed by those taking the decision to implement the move. Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Avondale DS0000015889.V309772.R01.S.doc Version 5.2 Page 28 - 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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