Inspection on 17/01/07 for Coxwold and Priory

This inspection was carried out on 17th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coxwold and Priory 10/03/09

Coxwold and Priory 27/03/08

Coxwold and Priory 18/01/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Coxwold and Priory 9 Coxwold Grove Hull East Yorkshire HU4 6HH Lead Inspector Christina Bettison Unannounced Inspection 17th January 2007 09:30 DS0000064809.V327518.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 DS0000064809.V327518.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. DS0000064809.V327518.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coxwold and Priory Address 9 Coxwold Grove Hull East Yorkshire HU4 6HH 01482 329226 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) Avocet Trust Carl Ince Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000064809.V327518.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Carl Ince is registered 17 Priory Grove, 33-35 Priory Grove and 9 and 9a Coxwold Grove and only undertakes managerial responsibilities for 186 Marlborough Avenue, Hull until 12th September 2005 and Flat 2 and Flat 3, 23 Trippett Street, Hull for up to 6 months from the date of registration. 18th January 2006 Date of last inspection Brief Description of the Service: Coxwold and Priory consists of 5 separate houses. They are all part of the Avocet Trust organisation. Avocet Trust is a registered charity. 9 and 9a Coxwold Grove are registered to provide care and accommodation for three adults with a learning disability in each house. The houses are in Gipsyville close to the Hessle Road shopping area to the west of the city. Both houses are three bedroom detached houses. Each house has a large sitting room, kitchen/diner, a large rear garden and a driveway to the front with parking space. The integral garage had been converted into an extra downstairs room with the addition of ensuite facilities including a walk-in shower. Upstairs there are 2 bedrooms, (1 has ensuite facilities including a shower) a separate bathroom and the third bedroom was being used as a store room/office/sleeping in room. There are shops, pubs, medical centre and post office all within walking distance. Public transport to various parts of the city is easily accessible. 33-35 Priory Grove consists of two separate houses and is registered to provide care for 5 service users. The home is situated within a housing estate to the west of the city that has recently been developed. Both units comprise of single storey accommodation. One unit is for one person and the other for four people. The unit for one has a lounge, kitchen/dining room, bedroom, bathroom and utility room. The larger unit has four single bedrooms, a sensory room, kitchen, lounge / dining room and utility room. Both have their own garden and separate private entrance. There are a number of shops, a post office, park and medical centre within walking distance. Public transport to various parts of the city is easily accessible and in addition some of the service users have their own car arranged through their mobility benefits. 17 Priory Grove is registered to provide care and accommodation for one adult with a learning disability. The house is in Gipsyville close to the Hessle Road shopping area to the west of the city. 17 Priory Grove is a three bedroom semiDS0000064809.V327518.R01.S.doc Version 5.2 Page 5 detached house. There is a large sitting room, kitchen/diner, a large rear garden with some landscaping and a driveway to the side with parking space. Upstairs there is a bedroom, bathroom and small sitting room for the service user, and a sleeping-in room for night staff. There are shops, pubs, medical centre and post office all within walking distance. Public transport to various parts of the city is easily accessible. Weekly fees range from £976 to £1915 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000064809.V327518.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in January 2007. During the visit the inspector spoke to the manager, staff and service users. Observations of care practice were made to assess service user satisfaction. Prior to the visit to the home questionnaires/surveys were sent out of which 4 health and social care surveys were returned, 4 relatives surveys were returned, 17 staff surveys and 6 service users surveys were returned. Service users were assisted to complete their questionnaires by staff and relatives and there were no significant comments. Staff commented that “they always give 100 ”, “clients are always priority”, “we always try to give the clients the good things they deserve”, “everybody is dedicated to the support and well being of the clients”, “we meet clients needs”, “ ensuring that service users are involved in the community, provision of activities, contact with families maintained”, “clients, live in nice surroundings”, “the staff are a great team and work hard to support clients and each other”. Areas for improvement from staff were noted as “regular 1-1 supervision”, “ a better computer”, “more communication, more supervisions”, “more sensory stimulation /equipment required”, “ would like people in the office to come and see the hands on work that staff do each day”, “more constructive support from senior management”. Comments from Health and social care professionals included “ throughout my involvement with Priory Grove I have witnessed a high level of professionalism at all times. Staff appear committed and well motivated with client welfare their priority concern.” Relative’s comments included “ the staff are very good with my sister and try to encourage her to do different things”, “I have absolutely nothing but praise for the care my daughter receives at Coxwold grove. All the carers are like a second mum to her. 100 all round.” The inspector looked around the home and looked at some records. Information received by us since the previous inspection was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home since the previous inspection. The site visit was led by Regulation Inspector Mrs. C. Bettison and lasted for seven hours. DS0000064809.V327518.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? Each service user has an individual plan that tells staff what their needs are. Service users are helped to develop their independence and develop into in adult. New staff are registered for basic training in how to work with people with a learning disability (LDAF induction). Policies and procedures (rules) have been changed to meet new laws and guidance, making sure that staff know what is expected of them and are able to meet service users needs. The gas and electricity supplies have been tested to make sure that the house is safe to live in. 17 Priory Grove has been redecorated and new furniture bought meaning that the service user now lives in a homely and comfortable house. Dangerous drugs are now kept in a safe place and records of when they are given are made meaning that service users are kept safe. DS0000064809.V327518.R01.S.doc Version 5.2 Page 8 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. DS0000064809.V327518.R01.S.doc Version 5.2 Page 9 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 DS0000064809.V327518.R01.S.doc Version 5.2 Page 10 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): 1,2,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives and/or advocates are given enough information prior to their stay in order for them to make an informed choice and their needs are assessed in full prior to admission ensuring that the staff are able to meet their needs. EVIDENCE: The home has a statement of purpose and a service user guide that has been updated since the previous inspection. Since the previous inspection there had been a planned discharge for a service user to a more appropriate service and a new admission to this service. The care file for the recently admitted service user was examined as part of the inspection process. The file contained a copy of the care management DS0000064809.V327518.R01.S.doc Version 5.2 Page 11 assessment and care plan. There was written documentation to evidence that the service user had been able to view/visit other services but with the support of family had chosen this service. For this service user there was good evidence of a planned transition period including tea time visits and overnight stays. However this was not a prolonged transition period because it was felt by all concerned that this would make the service user more anxious. This was well documented by all relevant parties and evidences that the home and staff are flexible to meet service users diverse needs. The admission had been reviewed and was felt to be going well by all concerned. The family were involved at all stages. DS0000064809.V327518.R01.S.doc Version 5.2 Page 12 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): 6,7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are met by adequate numbers of staff, however the quality of the service user plans and risk assessments is inconsistent meaning that service users assessed needs may not be met. EVIDENCE: Four care files were examined, one from each house within the service, as part of the inspection process. All care files had been tidied up and reduced into a manageable number of files. All individual plans, behaviour management guidelines and records are signed and dated and presented in a legible way. DS0000064809.V327518.R01.S.doc Version 5.2 Page 13 The quality of the service user plans was inconsistent. For two of the service users the individual plans had been developed to include everything that is detailed in the local authority assessment/care plan and detailed accurately what staff needed to do to meet service users needs, however in the other two the individual plans were very basic and needed much more detail. All four care files examined contained a personal information sheet detailing all relevant people in the service users life and where they could be contacted, a detailed likes and dislikes sheet, an individual programme plan and supporting management plans and risk assessments varying in the quality of the detail. There was evidence in care files of steps being taken towards meeting service users personal development need;E.g. During the previous inspection the inspector had observed an adult service user sitting on a member of staffs knee and being cuddled like a baby or young child. It was discussed with the manager and senior support worker at the time as it was felt by the inspector to be unacceptable practice and not promoting the service users adult status and not treating him with dignity and respect. During this inspection it was evident from the care file/IPP and observations that a desensitisation programme had been introduced to gradually reduce this behaviour and to provide the service user with the physical contact that he likes in a more age appropriate manner, this new approach seemed to be working with both the staff and service user adapting well. The service user had also been referred to the Psychologist for further advice/guidance. For one service user there were risk assessments to cover choking, moving and assisting and the risk of falls and for another there were risk assessment to cover meals, bathing, access to the kitchen, absconding and falls, however it was highlighted in this service users assessment that they had PICA and were at risk of ingesting unsuitable items, there had not been a risk assessment provided for this area of risk. One service user had had a FACS review on 27/4/06, another a FACS review on 15/11/05 and an Avocet review on 30/11/06, and another a FACS review on 27/4/06. The provider should alert the LA that service users are due for an annual review of care and the home should undertake an internal review at least 6 monthly for all service users. DS0000064809.V327518.R01.S.doc Version 5.2 Page 14 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): 11,12,13,14,15,16,and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of activities within the home and community means that all service users have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: The inspector was informed that none of the service users are engaged in work placements however all of the service users engage in a wide range of activities to continue their opportunities for personal development. DS0000064809.V327518.R01.S.doc Version 5.2 Page 15 One service users attends the local authority day services and some attend Avocets five senses day service and take part in activities such as keep fit, IT, art and communication skills. Service users enjoy an active social life which is detailed in their individual care files, such as bowling, swimming, shopping, visits to the hairdresser, walks and out for meals at the pub, visiting friends, two of the service users support Hull City AFC and have a season pass. Other activities enjoyed this year include trips to Disneyland, Paris, Flamingo land, Yorkshire Show, Avocets caravan at Skipsea. For two of the ladies who have autism their activity timetables are produced in a colour coded symbolised version and a copy kept in the service users room to remind of them of their activities for the week and ensure that their routine and structure is adhered to. Service users assist with household domestic tasks where they are able. Service users are supported to either visit their parents/relatives homes or are visited by them at their home and contact is welcomed. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Any restrictions are clearly documented in the care file and where possible agreed to by the service user. Some of the service users have been assessed by the dietician and the home follow the recommendations given. DS0000064809.V327518.R01.S.doc Version 5.2 Page 16 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): 18,19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of the service users are being met by the service, health colleagues and staff however the lack of attention to planning and recording means that service users health needs may not be met. The medication at the home is well managed however staff still need to undertake training to ensure that service users are kept safe from harm. EVIDENCE: Four service users care files were examined as part of the inspection process however the quality of recording was inconsistent. One care file examined evidenced that the service user had seen the GP in December 2006, and chiropodist in January 2007, however the last visit to the dentist was in 2003 and the optician in 2002. She had however had an occupational therapy assessment for appropriate seating and is admitted to the hospital yearly for a routine procedure. DS0000064809.V327518.R01.S.doc Version 5.2 Page 17 In another care file examined the service user had seen the chiropodist in January 2007, the GP in March 2006 and the dietician and dentist in 2004. She did however have routine appointments with the consultant Psychiatrist. In another care file the service user is prescribed rectal diazepam for seizures however this did not appear to have been reviewed and the inspector was informed that the service user had not required this medication for over 4 years. This service user had seen the dentist in December 2006, and although he had seen an optician in 2003 and was prescribed glasses there had been no follow up. The inspector was informed that he refused to wear his glasses but this was not documented anywhere and it had not been followed up with the optician. He did however have regular appointments with the consultant Psychiatrist. The other care file examined was for the recently admitted service user, she had seen the GP in January 2007 and had an appointment booked with the consultant Psychiatrist for March. Care files contained robust monitoring of food and fluid intake, skin condition and sleep patterns, epilepsy and behaviours where required. Health screening had been completed for some service users however the quality of this documentation was poor and needed re visiting. The Community Team Learning Disability have been approached to assist in the preparation of Health Action plans. Each service user must have health screening undertaken and the development of a health action plan to ensure that their health needs, the provision of specialist support is planned for and provided and that service users are helped to lead a healthy lifestyle. There are currently no service users self-medicating. There are written policies and procedures in place for staff to adhere to regarding administration of medication. Where individuals are prescribed controlled drugs, these are well managed and monitored by the staff and the use of a controlled drugs register and cabinet that meets the requirements of the legislation. PRN protocols were not in place to give staff clear instructions of when and what dosage needs to be administered. Other medication records were examined as part of the inspection and found to be in good order. The manager confirmed that not all of the staff had completed the administration of medication provided by the local authority that includes a competency check or a workbook to be completed following the training to ensure staff understand their responsibilities, therefore this remains an outstanding requirement. DS0000064809.V327518.R01.S.doc Version 5.2 Page 18 DS0000064809.V327518.R01.S.doc Version 5.2 Page 19 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): 22 and 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Complaints made to the manager of the home are handled appropriately and relatives are confident that their concerns will be listened to, taken seriously or acted upon. The staff team are aware of the Protection of Vulnerable Adults policies and procedures and their responsibility within these however further improvements in the individual plans and attention to health needs will ensure that service users are better protected from abuse, neglect and harm. EVIDENCE: There had been no complaints to the manager of the home since the previous inspection however the manager assured the inspector that she would keep a record of complaints with detail of any investigation and action taken. From examination of the training records it was evident that all staff have completed training in the Protection Of Vulnerable Adults Policies and Procedures and therefore understand their responsibilities within this however further improvements in the individual plans and attention to health needs will ensure that service users are better protected from abuse, neglect and harm. DS0000064809.V327518.R01.S.doc Version 5.2 Page 20 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): 24 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The environment provides service users with comfortable, homely, welldecorated and safe surroundings in which to live. EVIDENCE: 17 Priory Grove. At the previous inspection the inspector found the house at 17 Priory Grove to be dingy and uninviting. The décor was old fashioned and because of the small windows and dark wood in the house, it was dark. Carpets were worn and the majority of the furnishings were old and required replacing. DS0000064809.V327518.R01.S.doc Version 5.2 Page 21 This has been addressed with very positive results, the house has been completely updated, and decoration has taken place in the lounge, kitchen, bedroom, bathroom and upstairs sitting room. New furniture has been purchased throughout the house. A new kitchen has been installed and all of the appliances are new. 33/35 Priory Grove The houses have been updated, and some decoration has taken place and new carpets fitted. 9 and 9a Coxwold Grove Both of these houses still look fresh and new as staff keep on top of the decorating and repair and replacement of broken items. The recently admitted service user has had her bedroom decorated in the décor of her choosing. As part of the inspection all health and safety and the maintenance certificates were examined, all were available and up to date. The homes are safe and comfortable for people living there and provide a clean, comfortable and homely environment. DS0000064809.V327518.R01.S.doc Version 5.2 Page 22 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 adequate This judgement has been made using available evidence including a visit to this service. Service users needs are met by sufficient numbers of staff that are aware of service users complex needs and are able to meet them, however changes in the staff team, the lack of training, lack of detail in the individual plans and lack of support and supervision means that service users needs may not be met. EVIDENCE: The manager reported that since the previous inspection there had been a lot of staff movement across the site. Three staff had left since the previous inspection, one was dismissed, and one went to a new job and the other to undertake her nursing training. Several new staff have been appointed across the site and there has been some movement with staff moving from one house to work at another. DS0000064809.V327518.R01.S.doc Version 5.2 Page 23 It is hoped that this has settled down now and that the service will have a period of stability. The manager informed the inspector that where required new staff appointed have been registered for LDAF induction. Six new staff recruitment files were examined during this inspection and were found to be in order. Staff were not up to date with their mandatory training and this appeared to be largely down to staff being put forward for a place but then not attending the training. The manager stated that this was being dealt with by avocet through the conduct and capability procedure. The manager did not have an audit of what additional training staff had undertaken that is relevant to their needs. Although a number of the staff have completed the medication training, the manager stated that they were having trouble obtaining the certificates of completion from the Local Authority and there were still a number of staff to complete this therefore this remains an outstanding requirement. All staff have now had briefings on the Protection of Vulnerable adults. The numbers of staff that have completed NVQ qualifications has greatly improved, the service has 33 staff in total, 18 of which have got NVQ level 2 or above and the manager has got NVQ level 4.The inspector was informed that there are more staff to commence NVQ later this year. These Figures exceed the 50 requirement. The supervision records of six staff were examined as part of the inspection process. The provision of supervision does not meet the requirements, one staff had had 4 sessions since the previous inspection, another had had one in this service however she informed the inspector that supervision had been patchy in the service she worked in previously and none of her records had been forwarded on to her current manager, another staff member had only had two sessions in the year and another only 4 sessions in the year. Some of the supervisions that had been undertaken recently were of extremely poor quality. None of the staff had received an annual appraisal that identifies their training needs and this must be addressed along with the outstanding requirement for the manager to develop a training plan for the home. DS0000064809.V327518.R01.S.doc Version 5.2 Page 24 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): 37, 39,40 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager provides leadership; guidance and direction to staff to ensure that service users receive care that is appropriate to their needs however it is too early to assess whether the manager will be effective in promoting and safeguarding the health, safety and welfare of the people using the service and making the improvements needed that have been identified in this report. EVIDENCE: DS0000064809.V327518.R01.S.doc Version 5.2 Page 25 The manager of the service – Monique Rouse has only been in post since December 2006 and as yet is not registered with CSCI. She has a variety of skills, relevant qualifications and experience and has worked as a senior support worker in this service for a number of years. She has got NVQ levels 3 and 4 but she needs to complete the registered managers award. She has also completed risk assessment training, first line management training with Beverley College, equality and diversity training and has worked for Avocet Trust for 6 and half years. As part of the inspection all health and safety and the maintenance certificates were examined, all were available and up to date. Avocet have developed a quality assurance system for use within the home that needs to be further developed to ensure a systematic and planned approach to quality assessment, that gives all stakeholders an opportunity to contribute to the ongoing development of the service and that areas for improvement are clearly documented and action taken to improve evidenced. All of the Policies and procedures have been updated and it is Avocet’s intention to hold workshops to introduce the new procedures and ensure all understand them and work within them. Regulation 26 visits are undertaken by the trustees of Avocet Trust, the manager has commenced staff meetings and house meetings and management meetings take place monthly. The home is safe and comfortable for people living there and provides a clean, comfortable and homely environment. DS0000064809.V327518.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 3 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 x 2 3 x 3 x DS0000064809.V327518.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement The registered person must ensure that all service users have a detailed individual plan that covers all aspects of personal, social and health needs. The registered person must ensure that risk assessments are in place for all areas that pose a risk to service users. The registered person must ensure that records are maintained to evidence when service users have attended health appointments and outcomes. The registered person must ensure that health action plans are prepared for service users in partnership with health professionals. The registered person must ensure that all staff responsible for administering medication have received training and have their competency assessed. (Timescale of 31/03/06 not met) The registered person must ensure that there are written guidelines/protocol for staff to DS0000064809.V327518.R01.S.doc Timescale for action 30/06/07 2. YA9 13 (6) 31/03/07 3 YA19 13 (1a and b) 31/01/07 4 YA19 13 (1a and b) 30/06/07 5. YA20 18 (i) 31/03/07 6. YA20 13 (2) 31/03/07 Version 5.2 Page 28 7. YA35 18 (i) 8 YA35 18 (i) 9. YA36 18 (2) 10. YA35 18 (i) 11 YA39 24 12 YA42 13(4) follow giving clear unambiguous guidance as to when the PRN medication should be administered. (Timescale of 18/01/06 not met) The registered person must ensure that a training plan is developed for the staff team in the home. (Timescale of 31/03/06 not met) The registered person must ensure that all staff have an individual training profile (Timescale of 31/03/06 not met) The registered person must ensure that all staff receive formal supervision at least 6 times per year. (Timescale of 31/03/06 not met) The registered person must ensure that all staff are up to date with mandatory training. (Timescale of 31/03/06 not met) The registered person must further develop the quality assurance system within the home that ensures the views of service users and their families are taken into consideration and the service is continually improved. The registered person must provide evidence of design solutions to control the risk of legionella. 30/06/07 30/06/07 30/06/07 31/03/07 30/06/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000064809.V327518.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000064809.V327518.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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