Inspection on 21/05/07 for Avondale

This inspection was carried out on 21st May 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avondale 26/05/09

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Avondale 6 - 7 Nelson Terrace Redcar TS10 1RX Lead Inspector Brenda Grant Key Unannounced Inspection 21st May 2007 09:30 Avondale DS0000068782.V340585.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 DS0000068782.V340585.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 DS0000068782.V340585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Avondale Address 6 - 7 Nelson Terrace Redcar TS10 1RX 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) 01642 494509 F/P 01642 494509 Potensial Limited Miss Jillian Iley Care Home 12 Category(ies) of Learning disability (65) registration, with number of places Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the first inspection. Brief Description of the Service: Avondale is registered as a care home for up to twelve people with a learning disability. The Victorian building is two houses which are linked and they are as one home. All bedrooms are for single occupancy and have en-suite shower and toilet facilities. The home has large communal rooms and there are: a dining room, three lounges, a kitchen, bathing facilities and four bedrooms on the ground floor and eight bedrooms on the first floor. There are small gardens to the front of the house that overlook Redcar cricket field. The home is close to the sea front and the main shopping area. The fees, charged to residents, ranges from £750 to £1631 per week. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment was completed by the manager, one survey form that a resident has been assisted to complete and we carried out a visit to the home. The visit took place over one day, six hours ten minutes in total. Discussion and observation took place with residents, staff and the manager. We looked around the home as well as examining a number of records which included those for; residents and staff files, health and safety and maintenance checks, complaints, medication and minutes from staff meetings. The findings from the inspection were of the manager and staff creating a homely atmosphere and making every effort to meet the needs of individual residents. What the service does well: What has improved since the last inspection? This is not applicable as this is the first inspection. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 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 Avondale DS0000068782.V340585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Standard: 2 Resident’s individual aspirations and needs are assessed before they are admitted to the home. EVIDENCE: Resident’s files were examined. The files included care management assessments, giving details of the resident’s likes and dislikes, abilities and care needs. The file of the most recent resident contained a comprehensive Risk Assessment, informing how risks were to be managed. The home incorporates the assessment information into their documentation. Avondale is in the process of introducing new assessment ‘profile’ forms, where resident’s personal information and care needs are recorded. Views of residents and their families and Risk Assessments are also included in the new document. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 6, 7 & 9 The home has Care Plans, for each resident, which are regularly reviewed. The plans also contain Risk Assessments but they do not always include how risks are to be managed. Resident’s files inform how residents are supported and assisted with making decisions and living their lives as independently as they are able to, within their capabilities. EVIDENCE: A sample of Care Plans were examined. They gave information of resident’s needs, capabilities and general details about; likes and dislikes and lifestyle. The plans had been reviewed on a regular basis. The Care Plans include: the needs of the resident, how the needs are to be met, the desired outcome and why there may be restrictions on choice. Some of the information was as a Risk Assessment but there were not always full details of how the risk was to be managed. Care Plans were seen to be appropriately stored in a lockable cabinet. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 10 Staff said, where possible, residents are involved with developing the Care Plans and also when the plans are reviewed. The home has some residents who do not have the capacity to understand that information therefore the home makes sure reviewing officers, from the local council’s social services, healthcare professionals and families are regularly kept informed about the details of individual resident’s Care Plans. However, all residents are very able to inform staff of their likes and dislikes and this is recorded in the plans. Some of the Care Plans included comments from residents and/or their relatives. One resident said, “Yes” when we asked if s/he was happy with the care at the home. Residents can choose when to get up and go to bed. However, the manager said, on the days residents attend their planned day care services, staff encourage residents get up so that residents are ready to go out on time. One survey form confirmed this was the case. Staff said residents are supported when making decisions, such as: taking part in various activities and going on outings, shopping and anything the resident wishes to do. A resident, when asked what s/he liked to do, said, “Shopping and going out”. On the day of the inspection ‘site’ visit a support worker was assisting the resident to go out for a short walk to the shops. The manager said, “When a resident shows interest in any new activity, staff give support and encouragement so that residents have the opportunity to have different experiences”. The manager said, “This year some residents are planning to go on holiday to a cottage. The other residents, who are not capable or able to stay away for a holiday, are to visit the cottage so that they can enjoy some days out. The manager said she is to complete additional Risk Assessments for the holiday activities. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 15, 16 & 17 Service users are offered their choice of daily activities and can live their lives as they wish. Staff care for residents in the way they want. Residents individual diets are catered for but the home’s planned menu is only for one week. EVIDENCE: The manager said residents were encouraged and supported with their planned activities and there were also times when the home arranges extra activities and outings. Individual resident’s files included a record of all of the activities offered at the home. There were programmes, on the files, that gave details of all resident’s day care services; those records should only give the information for that particular resident. The manager and staff said, there are three residents who do not go to day care service but the home arranges other Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 12 activities for them. Staff said, the home tries to arrange activities that are suitable for each individual. One resident, who returned home from day care, was asked if s/he had a good day out? The reply was, “Yes”. The manager said, residents enjoy going to local facilities, there are: the seaside and amusements, shops, pubs, a youth club and parks. The home has two vehicles that are available for staff to assist and support residents when going further away from the home. The manager said, “There had been outings to Flamingo Land, the Metro Centre and Beamish Outdoor Museum”. The home keeps a record of resident’s daily activities in an Evaluation Book. Staff said, they help and support residents to keep contact with family and friends and families are regularly kept informed about their relative. The relationship between staff and residents was seen to be very comfortable and relaxed. Residents spoke freely to staff and staff spoke to residents in a respectful manner. The home has only a one week menu that has alternatives but residents are offered other food if they wish to have something different. A resident spoken with said, of the food, “I like it”. Most residents have special dietary requirements and all foods, for individual residents, are recorded. The home also monitors where there are areas of risk, such as: putting on weight and eating and drinking problems. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 18, 19 & 20 There is satisfactory support for health and personal care and the recording of medication is satisfactory. EVIDENCE: The home’s staff make sure personal care needs are carried out in a sensitive and correct manner. All personal support requirements are recorded in Care Plans. Equipment is provided to assist staff and residents with personal care tasks and staff records confirm staff having completed training for using the equipment. The home keeps records, all health care matters, with other general information of the daily occurrences for each resident. This does not allow the reader to easily determine the regularity and type of healthcare appointments that have taken place. The records included details of the outcome of healthcare appointments. All residents are offered annual healthcare checks and community nurses give ongoing healthcare support when it is needed. The manager said, home’s staff have regular meetings with health and social care Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 14 professionals and specialists and healthcare support is readily given to individual residents. Staff said, they support residents with arranging and attending healthcare appointments. The Medication Administration Records were examined. Records had signatures of the staff who administered or witnessed the medicines had been taken by the resident. Medication was kept in a lockable facility. Staff records confirmed designated staff have completed training for administering medicines, that is in addition to training provided by a pharmacy. The manager said, the home also arranges for staff to complete annual medication awareness training. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 22 & 23 Residents are confident their views are listened to and they are protected from abuse, neglect and self-harm. EVIDENCE: The home has a satisfactory Complaints Procedure and staff are aware of the procedure. There a book for recording complaints but there had been no complaints recorded. The home has a copy of the Department of Health Guidelines, ‘No Secrets’, which has procedures for safeguarding adults. Staff, spoken with, said they were aware of the safeguarding procedures, the Whistle Blowing policy and of the actions to take if there was a need to report an allegation of abuse. Staff files confirmed that staff have completed training for the protection of vulnerable adults. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 24 & 30 The home environment, within the limitations of ongoing maintenance work in the communal areas, is reasonable and it is clean and hygienic. EVIDENCE: There have been some improvements to the home environment. The kitchen flooring has been replaced and three bedrooms have been redecorated. The manager said, of the areas that have been redecorated, residents and their relatives had been involved with choosing the colour schemes. The dining room and lounge walls have suffered from dampness; the home is taking steps to have those areas damp-proofed and then redecorate the rooms. At the time of the inspection ‘site’ visit the wallpaper had been removed, in preparation for the work to be carried out. The middle lounge of the ground floor grubby had grubby walls and a stairway has cracked and peeling wallpaper, they need to be redecorated. The uneven flooring in the dining room needs to be levelled Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 17 and the hall carpet on the first floor has a join that is separating, it need to be made good. The home has plenty of room, for residents to move around, and the building is comfortable, airy, clean and free from offensive odours. Residents were seen to be freely moving around. Records confirmed there are systems to control the spread of infection. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Standards: 32, 34 & 35 Residents are protected and supported by the home’s recruitment procedures and staff are appropriately trained to care of the residents at the home. EVIDENCE: Staff files contained records confirming staff had completed the required basic training. The home had made arrangements for staff to update their training. Such as training for: first aid, medication awareness, people handling, fire awareness and infection control. Staff said, since a new provider took over the running of the home in November 2006, staff have been encouraged to further their skills and knowledge through providing various training courses. Staff files included information that staff had completed training for epilepsy awareness and the next course staff are to undertake is for managing behaviour problems. It is an excellent achievement that all but three staff has successfully completed the National Vocational Qualification Level 2 or 3. This far exceeds Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 19 the National Minimum Standards requirement of 50 of care staff attaining that qualification. Residents are supported and protected by the home’s recruitment policy. Staff files contained all of the relevant information, confirming the home follow the recruitment procedure. However, application forms did not have full details of staff’s past experience and employment history. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standards: 37, 39 & 42 Residents benefit from a well run home and they, and/or their relatives, are included with developments and changes that take place. Mostly the health, safety and welfare of residents and staff are promoted and protected but there are two regular checks that need to be carried out. EVIDENCE: The manager is qualified to National Vocational Qualification Level 4 in management and is a registered nurse. She is a qualified trainer and she is involved with delivering the training at the home. The manager has had four years experience as manager of the home. Staff said they think the home is well run and the new owner is actively making improvements to the service. In the main, most resident’s communication skills does not allow for residents Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 21 meetings to take place but residents, through their actions, clearly have the ability to communicate their views to management and staff. The home has developed quality assurance systems. The manager said, relatives had completed questionnaires and gave their views about the service. From all of the information gathered the organisation’s Quality Assurance Manager is developing an annual plan, which will take account of those views, when there are to be further improvements and developments to the service. The organisation carry out monthly monitoring visits to the service and the manager also carries out checks on a regular basis. A number of health and safety records were examined. Records for: accidents, fire, gas, electrical, water and equipment all confirmed there are regular monitoring checks and maintenance work carried out. However the home does not record that checks for bath and shower water temperatures have been regularly carried out but the home has ensured the valves that control the hot water are in order. Portable electrical appliances had not been checked on an annual basis and the last check was three years ago. Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 22 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 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 x Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 23 N/a 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 YA24 Regulation 23 Requirement The grubby walls of a lounge and the cracked and peeling wallpaper of the stairway must be redecorated, to keep the building in good order. The uneven flooring of the dining room must be levelled and the joining of a first floor hall carpet must be made good, for the safety of the residents. Areas where walls are suffering from dampness must be treated and redecorated. This work is already in progress. Records must be kept for: hot water temperatures and checks for portable electrical appliances, for the safety of the residents. Timescale for action 30/09/07 2. YA42 13 30/06/07 Avondale DS0000068782.V340585.R01.S.doc Version 5.2 Page 24 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 YA6 YA12 Good Practice Recommendations Full details of risk management should be included in resident’s files so that staff have an available record of the correct procedures. Resident’s files should only have details about that person and the programmes of activities should only have information for that person. 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