CARE HOME ADULTS 18-65
Avondale 62 Stratford Road Salisbury Wiltshire SP1 3JN Lead Inspector
Roy Gregory Unannounced Inspection 22nd September 2005 10:20 Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 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.V252038.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The total number of service users to be accomodated 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 individua ls receiving this service. Staffing for service users receiving respite care is therefore additional to the staffing levels below. 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. 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. 16th May 2005 4. 5. Date of last inspection Brief Description of the Service: The home dates from the 1980s. It was originally a health service establishment. 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. Bomford and Corinthian Housing Association currently own the property, but there are ongoing negotiations to transfer the property to another registered social landlord. 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 recently ceased. 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. Specialist bathroom facilities and other aids are provided. Adjacent to the home is a day centre operated by Turning Point, which is extensively used as a resource 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.
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 10:20 a.m. and 9:10 p.m. on Thursday 22nd September 2005, with a further visit the following day between 12:50p.m. and 1:50p.m. The inspector, Roy Gregory, met or observed all service users resident at the time and talked with five members of staff. The registered manager, Roger Mouncher, was available for the first hour of the inspection, after which one of the team co-ordinators (deputy managers) was available through most of the day and at the Friday visit. The inspector joined residents and staff for the midday and evening meals. A number of support plans were selected to compare observations of care, and staff comments, with written records. Other records consulted included those relevant to recruitment, staffing, health and safety, and protocols with external health professionals. All communal areas of the building were visited and four individual rooms were seen. During the inspection there was a discussion with Marianne Law, one of two Turning Point staff developing “Person Centred Planning” in the provider’s residential services. The inspector had the benefit of speaking with a relative visiting a resident in the evening, and has had some telephone contact and correspondence with relatives. Prior to completion of this report there has been further telephone contact with the manager. 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. The home has built up competence in using these protocols, with which all staff are familiar. Where residents have had to go to hospital, a regular occurrence for two in particular, the home has been able to supply support staff and documentation for reassurance to the resident and guidance to health staff. Another aspect of health care in the home, unfortunately, has been terminal care, which was provided in a caring and professional manner, again with good liaison with community nursing resources. Staff presented as very committed to the home’s aims of maximising residents’ opportunities for community involvement and developing greater independence even though much of the necessary engagement to achieve this is by outreach workers from outside, or by day services. There was a clear impact of the development of Person Centred Planning (PCP), Marianne Law saying staff were very receptive to the underlying principles. There was evidence of active work in progress by key workers and management in response to needs or wishes identified through the PCP process. Despite some reliance on agency staff to maintain numbers on shift, together with requests of existing staff to fill shifts, the staff team presented as
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 6 cohesive and working to commonly understood aims. A shift handover was very full, incorporating not only current issues and related delegation of duties for each resident, but also inviting individual staff opinions about meeting identified care needs, and sharing training information. Written records of care were good. Provision of meals and organisation of mealtimes were both of a high standard, support staff providing appropriate assistance and communication. Most of the building was cleaned to a very high standard, backed by good provision for everyday hygiene. What has improved since the last inspection? What they could do better:
It is unacceptable that two requirements from the previous inspection have not been met. Firstly, there were no arrangements in place for regular planned supervision of individual members of staff, although it was noted that the home has at least progressed to having trained senior staff in delivery of supervision, and delegated responsibilities for undertaking this. There is a requirement that details of actual arrangements made and planned be supplied to the Commission at the end of 2005. Secondly, it remains the case that there is not a photograph on record of every member of staff, as required by regulation. Related to this is a new requirement that, where an appointment is made of someone with a disclosed history of criminal conviction, the way this has been addressed should be documented. As stated above, the home is kept largely very clean. This standard was let down by unclean dining furniture, subsequently also identified by Mr Mouncher through his own audit process. There needs to be a cleaning schedule that ensures attention to such areas. There are also requirements to gain certification that the home is free of legionella bacteria, and to ensure there is a programme of weekly flushing of unused water outlets, in order to avoid conditions for build-up of bacteria. A further infection control issue is how staff understand and work with the existence of MRSA in the home, for which a policy and risk assessment are required. Advice should be available from the Health Protection Agency. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 7 Two further requirements are made, to improve external lighting at the home entrance for health and safety reasons, and to ensure that an aspect of an individual’s care, as provided by an external professional, is current, as there was a conflict between two differing documents, both undated. There is a recommendation about how existing good practice of supply of a resident’s relevant documentation to the hospital may be enhanced, and a second recommendation that some contents of support plans be archived, in order to assist staff to access immediately relevant information more easily. 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.V252038.R01.S.doc Version 5.0 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.V252038.R01.S.doc Version 5.0 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 People are admitted to the home only after a comprehensive assessment of need. EVIDENCE: At the time of writing this report, a vacant room was about to be occupied. The prospective resident was currently in hospital, but was known to the service by way of previous respite stays. Mr Mouncher had carried out a detailed assessment of need, on the basis of which a care plan was commenced prior to admission. Longer-term aims were already identified. Information was obtained from other professionals and the prospective resident’s family. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Support plans reflect individual needs and guide care practice, whilst Person Centred Planning is assisting individuals and their supporters to make decisions about the lives they wish to lead. Plans take account of risk in determining the degree of support individuals need to achieve within different areas of life. EVIDENCE: For each resident there was a support plan, divided into sections about different aspects of daily living. These components in turn had summaries of preferences, needs, likes and dislikes, and linked where appropriate to fundamental needs. For example, with regard to “domestic chores” for one resident, the plan highlighted the importance to them of feeling useful. Their abilities in tasks such as setting tables and folding laundry were shown. The person concerned was seen during the day to clear a table of their own volition, and later to accept a task suggested to them by a member of staff, which related to the resident’s needs. The written plan made cross-references where necessary, e.g. the mealtime support plan referred to a risk assessment about danger of choking, and there were several references throughout the plan to the person’s epilepsy. Risk assessments seen were of a satisfactory standard.
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 11 There was evidence in some of the plans of active review including of risk assessments. There was some build-up of material that had been noted recently by management oversight of plans, indicating a need to archive documentation that had ceased to impact on current delivery of care. A key worker described needs she identified for an individual, and the specific key worker tasks she undertook, which included work around communication. Her account was reflected both in the care observed during the day, and in the guidance in the resident’s support plan. All staff spoken to seemed well aware of the contents of support plans. The night team co-ordinator said she routinely directed both permanent and temporary staff to read the plans. In addition to the support plans for daily living, most residents are involved, with an individual “circle of support”, in Person Centred Planning (PCP). The provider Turning Point had appointed visiting facilitators in line with government “Valuing People” guidance. It was clear that the broadening and creative nature of life planning in this way was having an impact on staff views of the purpose and possibilities of placement in the service. There were a number of examples of new directions being investigated for individuals as a result of this process, including tasks being taken on by key workers. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 12 Lifestyle
The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, 15, 16 & 17 Arrangements are made for residents to experience a variety of focussed and leisure activities. Family members are welcomed, and invited to participate in planning for residents’ further development. There is an inclusive atmosphere in the home. Provision of meals matches individual needs within a sociable context. EVIDENCE: Key workers are required to ensure individual residents maintain active lives outside the home. Whilst staff would like more direct involvement in activities with residents, a view shared by some relatives, records confirm residents’ involvement in a variety of activity, with considerable reliance on day service provision and on Turning Point outreach workers. On the day of inspection, for example, four residents were out at the coast with two outreach workers, and one member of the home’s staff. Care records included documentation of outreach work, including photographs. There was evidence of the manager seeking increased funding for outreach and other activity work, by a variety of routes, as a direct result of issues identified through Person Centred Planning. The latter had identified one resident’s love of cinema, and a general need for that person to spend more time out of the home.
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 13 Some residents are accustomed to frequent visits from family members. There had recently been a barbecue evening to which family and friends had been invited. Whilst PCP had drawn in much family support, and in some instances included additional support work with family members away from the home, not all families had wished to engage in the process. For two individuals with no available family support, a local advocacy group was providing support within PCP meetings. All residents were on the register of electors. Throughout the inspection, sensitive caring practices were seen. The inspector joined the midday and evening meals, when staff sat with residents and engendered conversation, including making efforts to include those without verbal communication skills. The meals themselves were of good quality, allowing for choice and including plentiful availability each time of fresh fruit. One resident asked for sandwiches in the evening as he had had a cooked meal whilst on a trip out. The chef showed the current three-weekly menu, and demonstrated provision made for a special diet, and for puréed meals. A resident had a care plan for thickening food and provision in small quantities, linked to speech therapist assessment and guidance. A relative of a resident commented to the inspector about inappropriate clothing worn by some staff, considering this to be both disrespectful and possibly hazardous. This was not observed to be the case at inspection, and staff members and manager considered that staff accorded with the provider’s dress code, of which they were aware. However, it is appropriate to the environment to maintain awareness of presentation and practicality in this matter. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 14 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): 19 & 21 There is good guidance to staff, resulting in sound residents’ health needs, reinforced by liaison with However, management of MRSA needs direction, and relating to health has an element of risk. Provision for and death is good. EVIDENCE: For those residents where there were agreed protocols about health matters, these were kept together for ease of access, and staff were familiar with their contents. Some relatives considered they had had little choice but to agree such protocols when the home changed status from nursing to residential home earlier in 2005, although one said their relative’s admissions to hospital were no more frequent than had been the case previously. Notifications to the Commission have demonstrated adherence to protocols. Residents admitted to hospital have generally had care staff support there to reduce stress and to assist hospital staff to understand needs. A team co-ordinator said senior staff invariably took charge of health-related procedures such as suctioning, although there was evidence of most staff having received basic training in oxygen administration, moving & handling, medication administration and suctioning. There was evidence that clinical risk assessments were in process of being reviewed.
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 15 practice, in meeting health professionals. some documentation caring through illness For one resident who unfortunately endures rather frequent visits to hospital, current seizure, medication and other records were kept in a place from where they can be made immediately available to hospital staff. This was seen as good practice, but at the very beginning of a calendar month, the information immediately available may be insufficient unless care is taken to photocopy records for the last week of the previous month. Handover between morning and afternoon shifts was very full in content. Responsibilities for routine pressure relief duties for two service users were delegated. There was a discussion between all staff present about individuals whom they thought would benefit from referral to an occupational therapist. In one resident’s room guidance was seen for support to physiotherapy exercises. Care records demonstrated on-going liaison between the home and health personnel over management of a variety of medical conditions. An epilepsy risk assessment had been amended and clarified at review. It was backed by GP signature and contained seizure descriptions. Where fluid and turn charts were in use, they were well maintained. Staff had some knowledge of MRSA and its incidence in the home, but there was no policy or risk assessment seen to guide management of procedures to take account of this now or in the future. Where there were records of swabs having been taken, there was no follow up record to show results. For a resident subject to PEG feeding, an excellent document from the dietician headed “new feeding regime” was undermined by a similarly titled document with different information. As neither document was dated, there was a clear risk that an out-dated regime might be followed. A terminally ill resident was receiving home nursing in bed. A copy of the care plan was in place by the bed. Appropriate care to pressure areas was in place and observed care fitted both with the care plan and directions given at staff handover. There was evidence of family satisfaction with arrangements in place, and of prior documented family wishes. District nurse attention was readily accessed whenever requested. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 16 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 Provision for receipt of concerns and complaints is in place. EVIDENCE: The provider has a complaints procedure that is displayed in the home. Residents’ awareness or understanding of this may be limited. The person centred planning process is more likely to operate as a mechanism whereby matters of individual concern or dissatisfaction might come to light. It was evident that many relatives find the manager and staff approachable to air concerns, although the inspector is aware of a lack of confidence by some in the provider organisation. No formal complaints have been received by the home in the past year. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 17 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): 25, 28 & 30 Residents are able to benefit from private and communal spaces that meet their needs and wishes. There are high standards of hygiene, which could be enhanced by more rigorous cleaning schedules. EVIDENCE: Three individual bedrooms seen were very clean. Two were well furnished, and reflected the differing personalities of their occupants. For the other, new furniture was on order, the need having been identified by the resident’s key worker, and there were plans for redecoration. Communal areas presented well, although a sitting area upstairs had a rather makeshift feel. The PCP worker Marianne Law commented that two residents in particular were not keen to use the main sitting room downstairs. Mr Mouncher has said since the inspection that it is intended to develop the upstairs area. Since the previous inspection, good quality outside furniture had been obtained, along with a gazebo, allowing for use of the garden as an amenity through the summer. High standards of cleanliness were in evidence throughout the home. The housekeeper is to further her qualification to NVQ level 3. There remained the previously identified risk of rusted radiator covers in bathrooms, but the work to rectify this had been arranged. Staff spoke of routine use of aprons and gloves, as was seen, and to improve resources, wall-mounted apron dispensers
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 18 were on order. In all bathrooms and toilets there was provision of alcohol gel for hand hygiene. A support worker confirmed infection control training was a part of her two weeks’ LDAF induction training. The laundry was very well organised and clean. One shortfall in cleaning found was the undersides of dining furniture. Mr Mouncher intended producing a cleaning schedule for night staff to include such areas. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 19 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): 33, 34, 35 & 36 Staff present as a cohesive team, based on good communications and understanding of the tasks required. Training is planned to meet residents’ needs and is actively encouraged. Recruitment practice needs to be made safer by full adherence to regulations, and the lack of regular formal supervision is a serious shortfall. EVIDENCE: Basic staffing is to have five support staff on duty, although it is agreed this can be reduced at times of day when resident numbers at home are low. Rotas showed that usually there was a team co-ordinator on duty, and otherwise an experienced team member. There had been a number of staff losses through moves away etc., leading to a return to dependence on agency-supplied staff to uphold staffing numbers. Mostly, however, these were staff already familiar with the home and residents. Mr Mouncher had been putting himself on the care rota sometimes, including at night, but said this was more a device for extending his awareness of issues for his management role, than to make up staff shortfalls. Since the inspection he has been able to report successful recruitment of additional staff, and company agreement to recruit four more full time staff. At staff handover, staff were invited to fill shortfalls in staffing for the coming weekend, if they wished. There was discussion about staffing for those residents needing the support of two staff. Support staff considered they were adequate in numbers to meet
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 20 these needs, and described morning and evening routines. Priority was given in the mornings to those who were to go out, whilst in the evenings, as observed, there was more scope for flexibility as residents themselves had differing preferred timings. The manager and support staff agreed relatives’ observations that staff are stretched, and regretted that much engagement beyond basic care is provided by external staff. Nevertheless, on the day of inspection two residents went out on a one-to-one basis with support staff, as well as the four who went out for the day with outreach workers and a member of staff. It was also apparent that support staff were keen to exercise key work duties, including participation in PCP. Marianne Law, PCP worker, had given staff training in developing the value base of the home, and considered their response to have been excellent. As part of a large provider organisation, the home has the benefit of access to training resources, including arrangements for NVQ training, which is expected of all support staff. Since the change of status from nursing home, there had been an emphasis on induction of newly recruited staff, and internal training to ensure staff compliance with procedures relevant to service users’ immediate ongoing needs. Training opportunities were disseminated and discussed in staff handover. Recruitment practice is underpinned by the necessity to await confirmation from the company HR department that background checks have been completed, before progressing to appointment. In the case of staff where some record of criminal conviction existed, there was no record of how such information had been addressed in deciding to offer employment. There was also a lack of staff photographs on file. One member of staff said they had neither been asked to supply a photograph, nor had one taken at the home. This matter was subject of requirement at previous inspection. Team co-ordinators had attended training in supervision and appraisal, but there was not yet an established system for ensuring staff receive regular formal supervision, despite previous requirement for such a programme. The night team co-ordinator, who was working towards NVQ level 4, had devised particularly good written guidance for staff. There were minutes to show there had been staff meetings in April and August 2005. Overall communication between staff appeared to be good and valued, with the midday shift handover being an important point of reference. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 21 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 Despite staff change and shortage, there is a cohesiveness to the staff team and a high general regard for the management approach. Arrangements for collation and use of views of service users and their advocates have yet to be fully assessed by the inspector. Provision for health and safety monitoring is good, but some shortfalls were identified. EVIDENCE: Roger Mouncher has shown himself to be a manager who relates well to residents, their relatives and staff. Some established staff members spoke of the “team pulling together”. Despite a concentration on meeting every day high care needs, staff presented with a future focus. They had a good knowledge of the content of support plans and were motivated by involvement in PCP. It is regrettable that some relatives felt marginalized by the provider company. The inspector saw the monthly health and safety audit records, which now included certain aspects of fire precautions checks. Fire records all together were much better organised than previously. There was a training record in
Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 22 place, and a form for temporary staff to sign that they understood the fire precautions. Tracking of wheelchair maintenance needs was better organised in response to previous requirement. Advice was given about precautions to be taken in respect of legionella. Mr Mouncher has since said that within the company, advice was being sought about obtaining legionella analysis and certification for its properties. Two health and safety shortfalls were identified, namely a carpet trip hazard outside the lift upstairs, and a need for better external lighting between car park and front entrance. Mr Mouncher said that a change in contracted maintenance arrangements meant that such notified matters were now receiving much quicker attention that was previously the case. The home receives monthly unannounced visits from the provider company that conform to Commission expectations. These identify both good practice and shortfalls, based on observation and interaction, thereby assisting the management task. However, the home’s specific provision for quality assurance will be assessed separately. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 23 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 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score X 3 X X 3 X 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 3 1 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Avondale Score X 2 X 3 Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000015889.V252038.R01.S.doc Version 5.0 Page 24 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 Standard YA19YA30 Regulation 12 (1)(a) 13 (3)(4c) Requirement Timescale for action 31/12/05 2 YA19 3 4 YA30 YA34 5 YA34 6 YA36 There must be a policy and risk assessment to guide staff in working with people infected with MRSA. 12 (1)(a) For an identified service user, the feeding guide must be dated to show it is clearly related to current professional guidance. 17(1)(a)Sch There must be a cleaning 3(3)(m) schedule that includes routine attention to dining furniture. 19(1)(b), Personnel records must contain Sch2(1) a recent recognisable photograph of each member of staff employed at the home. (Requirement unmet from previous timescale of 30th June 2005). 19 (5)(a,d) Where a newly appointed member of staff has a record of criminal conviction, there must be a documented record of how this has been taken into account. 18 (2) Ensure that all staff receive supervision at least 6 times a year. (Requirement unmet from previous timescale of 30th June 2005).
DS0000015889.V252038.R01.S.doc 01/11/05 01/11/05 30/11/05 01/11/05 31/12/05 Avondale Version 5.0 Page 25 (Evidence for November and December 2005, and plans for 2006, to be submitted to the Commission by 31st December 2005) 7 YA30YA42 13 (3) 8 YA30YA42 13 (4)(c) 9 YA42 13 (4)(a,c) There must be a programme 01/11/05 for weekly flushing of all water outlets in the building that are not in regular use, as a precaution against legionella. The provider must obtain and 31/12/05 produce certification that the building is free of legionella bacteria. Adequate external lighting must 31/12/05 be provided at the front approach to the home. 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 YA19 Good Practice Recommendations Material in support plans that is not directly relevant to current provision of care should be archived. When care and medication records are provided to a hospital to assist care or assessment of a service user by hospital staff, care should be taken to ensure there is at least a week’s worth of documentation available. Avondale DS0000015889.V252038.R01.S.doc Version 5.0 Page 26 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
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