Inspection on 15/08/05 for Mount Avenue, 12

This inspection was carried out on 15th August 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mount Avenue, 12 02/04/07

Mount Avenue, 12 29/11/05

Mount Avenue, 12 25/11/04

Mount Avenue, 12 20/05/04

Mount Avenue, 12 31/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 12 Mount Avenue 12 Mount Avenue Bootle Liverpool L20 6DT Lead Inspector Janet Marshall Unannounced 15 August 2005 th 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 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 Stationary 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. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 12 Mount Avenue Address 12 Mount Avenue Bootle Liverpool L20 6DT 0151 944 2134 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Autism Initiatives Mrs Joan Frances Hazlett PC - Care Home Only 3 Category(ies) of LD - Learning Disability - 3 registration, with number of places 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD. 2. The service should employ a suitably qualified and experienced manager who is registered with the CSCI. Date of last inspection 25th November 2004 Brief Description of the Service: 12 Mount Avenue is a mid-terraced property situated in a popular residential area of Bootle. The service is operated by Autism Initiatives. The home is located close to all public transport, leisure and shopping facilities.The home is registered as a care home for three adults who have a learning disability.All three service users who currently live in the home are men. The ground floor of the accommodation provides a lounge, dining room, fitted kitchen, toilet/shower room, and upstairs is a bathroom, three large bedrooms and the office/sleep in room. The backyard of the house has recently been refurbished, a member of staff with the involvement of the service users carried out the work.The overall philosophy of care is to enable the service users to live as independently as possible and to promote integration of them into all aspects of 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspection visits are required at the home each year, this was the first. There has been no cause for any visits to the home since the last routine inspection in October 2004. The inspection was unannounced and took place over four hours. The requirements and recommendations from the last inspection report were discussed with a member of staff, some have been met but it was not possible to check them all due to the manager not being there. A partial tour of the home was conducted. Care records and other required records were inspected. Records that were examined included residents care plans, daily diaries, medical notes, medication sheets, staff rotas and records of health and safety checks. There was one resident at home at the time of the visit, the resident is unable to communicate verbally but expressed their views by use of sounds and body language. They indicated that they are happy with all aspects of the home. The care file of one resident was ‘case tracked’. Case tracking means that the inspector concentrates on the care given and experiences of one or more residents to ensure that the persons needs are recorded in their care plan and are being met. What the service does well: What has improved since the last inspection? Redecoration, repairs and replacement of carpets and furniture in the home have taken place since the last inspection. These improvements have contributed to making the home more comfortable and attractive for those residents who live there. An annual development plan for the home has been 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 6 provided which shows what the service is doing to improve the quality of life for the residents. 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. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 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 standard(s) 1 & 2 A good information pack is available at the home so that prospective service users are able to make an informed choice about living there. Information is available which show that individual needs are assessed and met by the home. EVIDENCE: There have been no new residents admitted to the home since the last inspection. The three men who have lived there for a number of years occupy all rooms. A file, which was available at the front entrance of the home, was viewed. It included very good information about the home for prospective residents, the information is also useful for those residents already living at the home. The information was well presented in large clear print with pictures to support the written information. Residents care files include information, which show that their needs are assessed by the home on a regular basis following which care plans are updated to take account of any change in needs. The information shows that the home can meet the residents needs as well as providing clear guidance to staff about what care is needed and how to provide it for each individual. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 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 standard(s) 6, 9 & 10 The service provides very good care plans for all residents, which are reviewed and updated regularly to ensure that changing needs are met. Residents care plans reflect they are encouraged to take responsible risks in their lives, which are safe and effective. Information about residents was stored securely to ensure that their confidences are kept. EVIDENCE: A detailed Care Plan was available for each resident. The plans include a great deal of information about individuals abilities, routines, likes and dislikes, medical and personal care. They are well written and include a good amount of information, which enable staff to meet each persons needs. Records showed that regular reviews take place ensuring that changing needs are identified and met. The care plan of one resident who was ‘case tracked’ matched other records and information gathered during discussion with staff. Staff told the inspector that the resident is encouraged and supported to take part in aspects of live in the home in accordance to his abilities, needs and wishes. This was supported by information recorded in the residents care file. Risk assessments were viewed for all residents. Records showed that risk assessments have 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 10 been developed, reviewed and updated since the last inspection ensuring that residents continue to take responsible risks. Care plans for residents were kept securely in the office. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15 & 17 Residents take part in a variety of activities both at home and in the local community, which are appropriate to their needs and wishes. Relationships are encouraged so that residents maintain contact with family and friends. Residents are encouraged to shop and prepare food that is healthy and enjoyable. EVIDENCE: Records and discussion with staff showed that many opportunities are provided for residents to take part in activities of their choice. A member of staff said that they help residents to shop for personal items as well as things for the home. Daily diaries and timetables viewed in resident’s care files showed that they are involved in a varied programme of activities, two residents attend a day centre during the week another resident who is supported in the home and the community takes part in various activities based on his needs, wishes and preferences. Records also showed that residents are supported and encouraged to develop and maintain contact with family and friends. There was plenty of fresh, tinned and frozen foods kept at the home. Staff spoken with said that they help residents to shop for food. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 & 20 Resident’s health care is well recorded and monitored to ensure that their health care needs are met. Medication was stored appropriately and records were well kept to ensure the protection of residents. EVIDENCE: Records show that the health care needs of residents are recorded in good detail they are well kept and up to date, they also show that all residents are supported to attend regular healthcare appointments. The changing healthcare needs of one resident are well documented in their care plan. Other information in the care file show that the home has involved other relevant professionals to support the resident with changing needs. All medication is administered by staff. Medication was in date and stored in a locked cabinet in the office. At this inspection records showed that all medication was signed for when administered. Items of unused or unwanted medication are returned to the pharmacist a record of this is kept at the home. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22 & 23 There were no recorded complaints since the last inspection. People are confident that their concerns or complaints would be listened to and acted upon. A clear complaints procedure was available so that residents can use it. Safeguards were in place to protect the people living in the home from abuse. EVIDENCE: Records showed that there have been no complaints made at the home since the last inspection. A member of staff spoken with said that they didn’t have any concerns or complaints about the home or the staff. They said that if they did they would feel confident about telling somebody. The homes complaints procedure was available in large clear print and in picture format. Copies of the procedure were available in the homes information pack and the staff handbook. A number of policies and procedures were in place to protect the safety, health and welfare of residents including a copy of Seftons Local Authority Protection of Vulnerable Adults Procedure (POVA), which clearly describes what action, must be taken in response to suspicion or evidence of abuse. Discussion with staff showed that they have completed Protection of Vulnerable Adults training. Staff spoken with showed a good awareness of the different types of abuse and their responsibility to protect vulnerable adults. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24, 28 & 30 The home was clean, tidy and maintained to a good standard providing a comfortable and safe environment for the people who live there. Cleaning timetables and routines were in place to ensure that a high standard of cleanliness and hygiene is maintained at all times. EVIDENCE: The inside of the home was nicely decorated, well lit and ventilated. The outside of the home was attractive and well maintained. Pictures, photographs and other items chosen by residents were displayed around the home. The home provides both private and adequate shared communal spaces for the use of all residents. Improvements have been made to the home since the last inspection, which include the redecoration of both the dining room and the lounge, replacement of the lounge carpet, three-piece suite, dining suite and curtains. The bathroom floor, which was damaged due to a leak, has been repaired and re covered. A resident was observed using all communal areas of the home. The Resident indicated that he is happy with all aspects of the home. Keeping the house clean and hygienic is important to residents and staff this showed by how clean the house was. A member of staff said that residents are encouraged to help around the house, residents ability and level of involvement is recorded in their care plans. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 & 33 Staff have completed the required training, which enables them to meet the needs of residents. Staffing arrangements during the night are not appropriate to meet the needs of residents, this has the potential to put residents and staff at risk. EVIDENCE: Staff rotas showed that sufficient numbers of staff are on duty throughout the day. There is usually at least two staff on duty during the day when there is more than one resident at home. Records and discussion with a member of staff showed that the current arrangement of one sleep-in staff during the night is not sufficient in meeting the needs of one resident who is often awake for periods throughout the night disturbing other residents and requiring the support of the sleeping member of staff. The nighttime staffing arrangements need to be reviewed to ensure that they are appropriate to the needs of the residents. Staff records were not available because the manager who is the only person that has a key locked them away, this is to protect staff confidentiality. A member of staff spoken with confirmed that he has completed most of the training that is required as well as training that is specific to the needs of the residents. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 16 The member of staff said that they took part in an induction programme during the first part of their employment. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 40 & 42 The manager of the home is positive, approachable and inclusive benefiting both residents and staff. Not all the required Health and Safety checks have been carried out which has the potential to put residents and staff at risk. Some of the homes Policies and Procedures that were in place to protect the health, safety and welfare of the residents and staff have not been reviewed for some time to ensure that they are relevant and up to date EVIDENCE: Staff said that the manager is very approachable and supportive of both residents and staff, the manager was also described by staff as being positive and inclusive. A member of staff said that they have completed health and safety training. Certificates were not available to support this because they were locked away with other staff details. A detailed health and safety manual was available at the home. The manual included certificates of safety checks and details of tests carried out on the environment. The gas certificate was out of date, therefore there was no 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 18 guarantee that the gas system is safe and in good working order, this is a potential health and safety risk to residents and staff. An immediate requirement was given on the day of the inspection. The home responded to this by having a full safety check of the gas system within the timescale given. An up to date gas safety certificate was obtained which the inspector saw. Small appliances used in the home have not been P.A.T tested since May 2004, they must be tested annually to ensure that they are safe to use, again this is a potential risk to residents and staff. Other records were well kept and up to date. All the required health and safety policies and procedures were available in the homes handbook, a number of the homes policies and procedures have not been reviewed for some time these should be reviewed, and updated if necessary to ensure that they are relevant and up to date. 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 19 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 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x 3 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 12 Mount Avenue Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 4 x 2 x 2 x F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 20 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 YA33 Regulation 18(1)(a) Requirement The manager must ensure that staffing arrangements at night meet the needs of residents. The manager must ensure that an up to date gas certificate is available at the home. The manager must ensure that all small appliances are P.A.T tested anually. The manager must ensure that the homes policies and procedures are reviewed to ensure that they are relevant and up to date. Timescale for action 31/09/05 2. YA42 13(4)( c) immediate 3. YA42 13(4)( c) 31/09/05 4. YA40 17(3)(a) 31/11/05 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 Good Practice Recommendations 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crsoby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 12 Mount Avenue F53 F03 12 Mount Ave S5226 V245091 15.08.05 Stage 4.doc Version 1.40 Page 22 - 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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