Inspection on 01/12/05 for Avonridge

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avonridge 17/07/08

Avonridge 19/07/06

Avonridge 05/07/05

Avonridge 21/12/04

Avonridge 23/08/04

Avonridge 02/03/04

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 Avonridge Front Street West Bedlington Northumberland NE22 5TT Lead Inspector Karena M Reed Unannounced Inspection 1st December 2005 5.30 DS0000000645.V269649.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 DS0000000645.V269649.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. DS0000000645.V269649.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avonridge Address Front Street West Bedlington Northumberland NE22 5TT 01670 - 820313 01670 820313 kathleen.morrison@nap.nhs.uk/ communityh 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) Northgate & Prudhoe NHS Trust Mrs Kathleen Morrison Care Home 4 Category(ies) of Learning disability (4) registration, with number of places DS0000000645.V269649.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2005 Brief Description of the Service: Avonridge is a purpose built bungalow situated to the back of the main street in Bedlington. The premises are furnished and decorated to a satisfactory standard with access for the disabled and with adequate car parking space to the side. All of the bedrooms are single with communal bathing and toileting facilities situated around the home. There is adequate communal lounge and dining space. The home is close to local amenities and transport networks. The home is owned by Northgate and Prudhoe Trust, a local provider of services for people with learning disabilities and associated disorders . DS0000000645.V269649.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not given prior notice of this inspection that took place over 2 and three quarter hours. A partial tour of the premises took place and a sample of care records were inspected as well as other records. Records included: 4 care plans, the fire log record, the accident book, admission/discharge register, complaints record, staffing rotas, daily communication book and service users personal allowance records .Two support workers were spoken to during the inspection. Time was also spent with 4 service users during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Staffing records to be kept on the premises. Replace light bulbs promptly. To investigate the damp smell to the side of the building identified at the time of inspection. To provide a programme of decoration and make good décor around the building . DS0000000645.V269649.R01.S.doc Version 5.0 Page 6 Reattach all the radiator guards around the building which are standing freely. Make good the plaster work to the damaged bathroom wall. Ensure the living room and bedroom identified at the time of inspection are heated to an adequate temperature. To provide training about visual impairment . Review the staffing levels over night. 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. DS0000000645.V269649.R01.S.doc Version 5.0 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 DS0000000645.V269649.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this inspection. EVIDENCE: DS0000000645.V269649.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 There are good arrangements in place to ensure that service users’ care needs are met. Health and social care needs are clearly addressed and the staff team are fully informed. Service users’ are well supported by staff and the necessary levels of support are provided due to the detailed care plans that show the level of care and support that staff need to provide. Service users are encouraged to be involved in decision making and they are encouraged to communicate and make their views known other than verbally . Service users know that information about them is handled appropriately, and that their confidences are kept. EVIDENCE: Care records looked at showed after referral to the service an assessment of the care needs of the service user is carried out to ensure support and care can be provided by the agency. A plan of care and support is drawn up by the senior , then a system of review is introduced to ensure care needs are revised DS0000000645.V269649.R01.S.doc Version 5.0 Page 10 regularly in case they change. Documentation emphasises the need for service users to be central to the delivery of care, e.g “Personal Futures Planning”. Staff spoken to stated they receive training as part of their induction regarding basic care principles and that there is on going training for all staff regarding the rights of service users. The comprehensive policies and procedures manuals also provide information for staff about care of service users. Conversation with two staff members and service users showed the emphasis is for service users to be responsible for decision making in their own lives, as far as possible. Staff provide the necessary levels of support to maintain or increase an individual’s independence . The policies and procedures manual also contains an up to date policy about confidentiality and when information about a service users may be shared with a third party. DS0000000645.V269649.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 The philosophy of the service is for guests to access and participate and use community facilities wherever possible e.g leisure, health, spiritual, social, educational needs, etc. Social activities are managed creatively and provide daily variation and interest for people living in the home. Visitors are made welcome or staff support guests to maintain contact with family and friends as they wish. EVIDENCE: Service users spoken to confirmed that they are asked and involved in making decisions about their lives eg choice of food, activities, rising, retiring routine. Service users records and daily recordings about care and support provided by staff provided evidence that all service users are consulted and asked their opinion and encouraged to make decisions. DS0000000645.V269649.R01.S.doc Version 5.0 Page 12 Records and conversation with staff and service users showed staff support service users and encourage them to become more self sufficient in aspects of every day living. Service users all pursue their own individual hobbies and interests eg ten pin bowling, shopping, karaoke, visiting the local pubs, meals out, shopping, theatre trips, computing, fishing, horse riding,bingo, visiting local attractions on the coast. Service users attend day services during the week such as adult training centre, gardening projects and Hepscot Park. DS0000000645.V269649.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 There are excellent arrangements in place to ensure that service users’ health care needs are met, care plans outline the needs to ensure that the staff team are fully informed and aware of the support they need to provide. EVIDENCE: Care plans and case records inspected, contained relevant individual plans of care detailing care and support required for some complex needs. Records showed when service users’ had seen health professionals e.g doctors, community nurses, etc. The medication system was not examined during this inspection. Staff receive training before they can administer medication to service users. DS0000000645.V269649.R01.S.doc Version 5.0 Page 14 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 There is a complaints procedure, which works well internally as service users and their relatives have confidence that they can raise any issues and know that they will be dealt with. Staff have a knowledge and understanding of Adult Protection issues which protects service users from abuse. EVIDENCE: The service has a complaints procedure. There has been one complaint received by the service that has been investigated within the timescale. An accessible complaints procedure is available for the use of service users and they were encouraged and supported to use them in order to raise any issues of concern with the staff team. Staff receive training about the Protection of Vulnerable Adults which is updated when necessary. DS0000000645.V269649.R01.S.doc Version 5.0 Page 15 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): 24,25,26,27,28,29,30 The home is relatively well maintained with good quality furnishings in the communal areas, which creates a pleasant and homely environment for those living there. The décor requires attention in some areas of the building. All service users enjoy their own bedrooms . Service users have the use of a lounge and dining room. There is a good standard of hygiene around the home. Some systems are in place to provide a safe environment for service users and staff. EVIDENCE: A tour of the premises was undertaken and a small number of bedrooms viewed. The home is quite well maintained and there is an ongoing programme of decoration and refurbishment, however some areas of the building are still in need of painting. Around the building it was noticeable the radiator guards were not secured to the walls for the safety of service users but were free standing and could easily be removed. There was an unpleasant dank, damp smell to one side of the building and this was evident in some bedrooms. One bedroom and the lounge temperature was quite cool. The DS0000000645.V269649.R01.S.doc Version 5.0 Page 16 bathroom wall was damaged where the door handle banged into the wall and so caused the plaster to fall out. There is a lounge and dining room. Service users bedrooms were well furnished and comfortable, service users being encouraged to personalize their own bedrooms . There are an adequate number of bathrooms with equipment to help those with physical disabilities and some separate lavatories around the home. There are good laundry facilities in place and staff receive training about infection control. There is a garden for the use of service users. DS0000000645.V269649.R01.S.doc Version 5.0 Page 17 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): 31,32,33,34,35 Minimum staffing levels are maintained which means that there are only enough staff on duty to meet the needs of service users at certain times through the day. Staffing levels at night should be reviewed due to the needs of service users. There are good training arrangements in place, which means staff are given a thorough grounding in the areas they need to know to provide good care and enhance their personal development. A formal system for the supervision of staff is being used. EVIDENCE: Examination of staff rotas and discussion with the members of the staff team provided evidence that the numbers of staff are as follows: 7.30am- 9.00pm 2 9.00pm-8.00am 1 The manager’s hours are included in the above .No ancillary staff are employed , staff carry out food preparation, cleaning and laundry. Staffing levels at DS0000000645.V269649.R01.S.doc Version 5.0 Page 18 night should be reviewed due to the needs of service users and their levels of dependency and to ensure the safety of service users and staff. A full time support worker’s vacancy has just been filled. Staffing records were not available on the premises to check the organization’s vetting and recruitment procedures. Staff confirmed that supervision is carried out regularly on a monthly basis. Staff stated that they enjoyed working in the service and were observed to be kind, caring and respectful to service users’ at all times. Discussion with staff confirmed that they receive induction training. New members of staff follow LDAF, Learning Disability Award Framework in order to give people more insight into the needs of people with a learning disability. Where new inexperienced staff are employed, they work as an extra member of the shift, which is good practice. Staff are pursuing National Vocational Qualifications at different levels, 60 of staff members have achieved NVQs’ at level 2, and 40 are currently studying for the award. Staff confirmed that they also receive advice and /or training in other areas, such as challenging behaviour, values and rights of people with learning disabilities, person centred planning and the necessary statutory training. There was no evidence that staff had received up to date training about working with people with visual impairment. DS0000000645.V269649.R01.S.doc Version 5.0 Page 19 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): 37,38,40,41,42 The manager provides clear leadership throughout the home, which ensures all of the staff team are aware of their roles and responsibilities. The service’s policies and procedures that are in place ensure that service users’ rights and interests are protected. There is an excellent standard of record keeping which shows service users rights and interests are maintained. There are adequate health and safety measures in place to ensure the safety of all who live and work in the home. EVIDENCE: The manager, Mrs Kathleen Morrison has managed the home for several years. She is currently studying for the Registered Manager’s award . The positive comments of service users’ and staff give confidence that the manager provides good leadership throughout the home and promotes a philosophy of involvement of service users and staff. DS0000000645.V269649.R01.S.doc Version 5.0 Page 20 Discussion with the staff members also provided evidence that the staff are supported in their roles through regular supervision meetings which take place regularly. Staff meetings take place approximately six-eight weekly and the manager attends managers meetings monthly. Staff as well as developmental training, also receive training in moving and handling skills, fire safety, first aid, infection control and food hygiene. Health and safety hazards identified were the unsecured radiator guards around the building. DS0000000645.V269649.R01.S.doc Version 5.0 Page 21 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 x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 4 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 4 17 Standard No 31 32 33 34 35 36 Score 3 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 2 x DS0000000645.V269649.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 13(4)© Requirement The light bulbs must be replaced immediately in the interests of health and safety. Radiator guards must be re-secured immediately. The programme of decoration to the building must continue The damaged bathroom wall must be repaired. Night staffing levels must be kept under review. Ensure that the information specified in Schedules 2 and 4 of the Care Homes Regulations 2001 is available for inspection in the home outstanding as of October 2004 Timescale for action 02/12/05 2 3 4 1 YA24 YA24 YA32 YA41 23(2)(d) 23(2)(b) 18(1)(a) 7,9,17,19 01/04/06 01/02/06 01/02/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA35 Good Practice Recommendations To provide up to date training for staff about visual impairment. DS0000000645.V269649.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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