CARE HOME ADULTS 18-65
Mount Avenue, 12 12 Mount Avenue Bootle Liverpool Merseyside L20 6DT Lead Inspector
Elaine Stoddart Unannounced Inspection 2nd and 17th April 2007 09:30 Mount Avenue, 12 DS0000005226.V335375.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 Mount Avenue, 12 DS0000005226.V335375.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. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Mount Avenue, 12 Address 12 Mount Avenue Bootle Liverpool Merseyside L20 6DT 0151 944 2134 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) www.peterhouseschool.org Autism Initiatives Mrs Joan Frances Hazlett Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the CSCI. 29th November 2005 Date of last inspection 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 residents 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. At the rear of the house is a backyard, which is attractively paved and furnished for the use of residents. The overall philosophy of care is to enable the residents to live as independently as possible and to promote integration of them into all aspects of life at home and in the community. The cost for the service ranges from £1000.55 - £2000.00 per week depending on need. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The site visit took place over two days as the manager was on leave during the first visit. During the first visit the staff on duty demonstrated they are fully aware of how the home is run, had access to all the information and records they need and were able to provide detailed information on the care and support in place. The visits involved the viewing of records and systems in place, interviews with staff on duty and observation. Discussions took place with the manager, Joan Haslett and three of the care staff on duty. The residents accommodated have high level needs and limited communication. Observation and interaction with staff on duty was made during the two visits. The manager, prior to the site visit completed a pre inspection questionnaire, which gave details of the service provision. Satisfaction surveys were not distributed to residents, as they are unable to complete these due to their communication difficulties. Comments people spoken with and observations made are incorporated within this report. What the service does well:
A statement of purpose is in place, which fully outlines the service provided and is provided in a picture format to enable people with a learning disability to have some understanding. The service provides residents with full assessments and a care plan that clearly reflects all their needs. Regular reviewing and updating of the plans ensure that residents care needs are consistently met and that changing needs are identified. The staff spoken with are fully aware of the residents needs and demonstrated their knowledge of this when spoken with and observed caring and interacting positively with the residents during the visits. Each resident has a key worker who is involved in support plans and care reviews to ensure care is closely monitored. The staff are involved in regular staff meetings to keep them up to date with developments, discuss changes and the day to day running of the home. Records viewed were found to be clear, concise an available to staff for reference. This ensures they are able to keep up to date with progress and are included in the daily reporting on all the residents care. There have been no complaints made since the last inspection.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 6 Residents maintain full daily activity programmes and supported to access the community, holidays and interests of their choice. The residents are encouraged to maintain contact with family and friends and visitors are able to call at the home at all times. Routines in the home are flexible to meet the residents’ lifestyles. Menus are in place and residents are provided with a choice of meals. A sufficient budget is available to ensure wholesome, appetising meals are provided. Staff were seen encouraging residents to make choices and decisions therefore promoting their independence. Assistance and support was provided, which is consistent with the resident’s plan of care. Sufficient staff are on duty to meet the needs of the residents and management support is available at all times. A staff training programme is in place and is ongoing to ensure the staff are equipped with the skills to carry out their roles. The atmosphere in the home is warm and welcoming and the residents were observed to be relaxed and comfortable in their environment. Staff were observed supporting residents to move freely around the house as part of an independent lifestyle. Personal support was observed to be provided in a way that ensures their privacy and dignity at all times. Care practices observed throughout the inspection show that staff respect the rights, privacy and dignity of residents. The home is comfortable, well maintained and furnished to suit the needs of the residents. Resident’s bedrooms are decorated and furnished to a high standard and reflect their individual lifestyles. Residents are encouraged to display personal items giving the house a ‘homely’ feel. Indirect observation and discussions with staff demonstrated they are committed to providing a high standard of care and are caring and sensitive to the needs of the residents. The manager confirmed the company is responsive to repairs and improvements to ensure the home is maintained to a good standard. A manager who is positive and approachable displayed a clear understanding of the residents needs and is committed to providing the care and support required. A core group of seven regular care staff support the residents to ensure continuity of care. Staff spoken with provided positive comments on the support and direction provided by the manager: “I get a lot of support and supervision and we all help each other”. “The manager is always available if we need her”. “We have a good team”. Quality monitoring of the service takes place via monthly Regulation 26 visits to the home. A Quality Network team involves representatives from all involved in the residents’ care and meets regularly to discuss residents’ rights, outcomes and new developments. A parent of one of the residents is a representative on the board of trustees. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 7 The home has a robust procedure for the administration of medication. All administrations are countersigned, as this is company policy. Resident’s finances are closely monitored and robust records are maintained, all transactions accounted for and receipts obtained. What has improved since the last inspection? 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. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 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 Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Information is available to prospective residents in a suitable format on the service. Full assessments of need are obtained prior to any admission to ensure the home can met their needs. No emergency admissions are made. Contracts of terms and conditions are in place. EVIDENCE: The home provides a detailed statement of purpose and service users guide, which is in picture format to enable the residents to understand. It contains pictures of areas of interest, the house and rooms available. Information on the manager, staff, their qualifications and experience are also included. No resident is admitted on an emergency basis as all prospective residents are initially assessed at the companies assessment centre to ensure their needs can be met. All those involved in their care are included within this planning process. Two care files were viewed and these contained full and clear assessments of need, which demonstrated each residents capabilities and the areas of support required by staff. Discussion with the staff on duty demonstrated they are fully aware of the needs of the residents. The three residents have been accommodated at the home for some years and there have been no new admissions since the last inspection.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 10 Assessments in place covered all aspects of the residents care and included: support plans, routines, communication needs, risk assessments, positive targets, personal details, health care needs, individual pen pictures, medication, activities, personal support required and social contacts/family. Two residents require 1 –1 support at all times and this is recorded in their assessment and care plan details. The staff are fully informed of the needs/risks and support required and confirmed this when spoken with. Each resident has a contract of terms and conditions, which outlines the fees and charges. The service has access to independent advocacy services should the residents wish this. Two of the residents have regular family contact. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 11 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): Standards 6,7,9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans fully reflect the care required, monitor changing need and outline personal goals of the residents. The residents are encouraged to make decisions and are supported to take risks as part of their individual lifestyles. EVIDENCE: The care plans are developed from detailed assessments and cover all aspects of the personal, social and health care needs required by the residents. Each plan showed clearly the individual care needs of each resident and how staff provide the support to meet those needs. The residents have high level needs and are supported by sufficient numbers of staff on duty. Care plans identified long term and short term goals and positive daily routines are set to encourage each resident to achieve. The care staff are fully involved in the care planning process and daily reports are maintained to monitor progress. Personal support programmes outline clearly what each resident requires support with and how this is to be provided. This ensures that the staff are aware of residents individual needs, abilities and how to communicate with them effectively. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 12 All risks are recorded and reviewed regularly and 1 –1 support in place for those residents who need this. Staff spoken with showed they are fully aware of the residents needs, risks and what action to take to provided positive support and direction in areas such as, road safety, eating, personal care and medication. Systems are in place for managing challenging behaviour. Set goals and strategies are in place and staff are provided with detailed information on what may trigger this and what action to take. Discussion took with the manager on this subject who confirmed how these strategies have improved the behaviour of one resident. Discussion with the manager confirmed her ‘in depth’ knowledge and awareness of residents’ individual needs. She is committed to ongoing progress to ensure the residents are involved in making choices, decisions and have access to services they need. Care plans are reviewed regularly, involving other professionals/relatives/representatives, to monitor changing need. Care plans give clear guidance to staff on how to communicate effectively with the residents and how to encourage them to make choices and decisions. The residents are unable to manage their own finances and robust systems are in place to ensure this is closely monitored. All transactions made are recorded and receipts obtained. The manager is appointee for all three residents are their families are also involved in their financial affairs. All three residents have their own bank accounts and monies in the home are securely stored. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,14,15,16,17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity for personal development, take part in appropriate activities and maintain contact with family, peers and the community. Healthy meals are provided in a flexible, homely environment. EVIDENCE: The residents were observed using all parts of the home with staff assistance when required. Information in care files provide staff with clear information about how best to support residents to move about the home freely and safely whilst respecting their right to do so. Care files viewed identified long and short-term goals and the residents are encouraged to take part in the daily routines of the home, such as helping to wash and dry crockery. This ensures that the resident’s skills and abilities are continually developed. All daily activities, achievements and progress made is recorded and monitored closely by the staff/manager. Positive Interactive Support Plans (PISP) are reviewed 3 monthly to monitor progress and support.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 14 Two of the three residents attend day care facilities. All are involved in full activity programmes and records are kept of those taken part in. Activities include: pub meals, gym, theatre and trips out. One of the residents recently went on a trip to the Grand National with staff support. Staff support the residents to take annual holidays, which have taken place at Grange over Sands and Scotland. Discussion with the manager and staff confirmed the three residents have integrated well in the local community in which they live. Those residents who have families are encouraged to maintain contact and the staff support them to do this by providing taking them for visits and have visitors at the home when they wish. Staff were observed to interact positively with the residents and maintained their dignity and respect at all times. Meals times are flexible and unhurried to meet the daily routines of the residents. Some residents require support during meal times and this was observed to be provided in a sensitive manner. The residents are offered a healthy diet and encouraged to make choices. A sufficient household budget is in place to cater for the residents and staff. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 15 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): Standards 18,19,20,21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported in the way they prefer. Well-structured care plans ensure that residents’ needs are met and their death wishes sought. Medication policies and practices are robust. EVIDENCE: Staff were observe to support all three residents with their personal care in a sensitive and flexible way and in the privacy of their own bedrooms. Staff were also seen knocking on bedroom doors before entering. The service maintains detailed records of every contact that each resident has with medical and health care professionals. In addition to this, detailed information of the health care agencies involved are recorded for each resident in their individual plans of care. Records show that all residents receive appropriate health care that they need and access services when required. The home has a robust procedure for the administration of medication. The procedures are simple to follow and available for access to all staff responsible for administration.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 16 Risk assessments are in place to show that the residents require assistance in this area. All administrations are countersigned, as this is company policy. Staff are trained in this area. Prescribed medication for residents is recorded within care files. Medication is delivered from blister packs and securely stored in a locked cabinet. All received/returned medication is recorded. Sample signatures are in place for staff who administer. Information is available for all staff on the side effects of the prescribed medication and the signs to be aware of should the resident be effected by this. There are no controlled drugs administered. Care files viewed showed that the death wishes of the residents have been discussed and recorded and will be handled with respect should this occur. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 17 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): Standards 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Abuse policies and procedures are in place to protect the residents. EVIDENCE: Training records failed to demonstrate that staff had received training in the protection of vulnerable adults. Staff spoken with confirmed their clear understanding of abuse and the procedures to follow. A copy of Liverpool and Seftons’ ‘Safeguarding Adults Policy’ is available for staff access. A recommendation for staff to be trained in this area is contained in this report. The statement of purpose contains the complaints and abuse procedures in a picture format. The company have their own Adult protection Officer. There have been no complaints recorded since the last inspection. An advocacy service and/or relatives support are available should residents require assistance. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 18 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): Standards 24,25,26,27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s bedrooms are furnished and personalised to suit their individual needs and lifestyles. Residents live in an environment that is well maintained and well decorated. EVIDENCE: All residents’ bedrooms were viewed and were found to be individually furnished, personalised, clean and comfortable. Since the last inspection a number of improvements have been made to the home and these are mentioned in the ‘What has improved’ section at the beginning of this report. On the second visit the staff were setting up new wardrobes and drawers in one of the residents rooms and were preparing for it to be decorated. Each resident has a lock on their door and a separate lockable facility for their personal use. Due to the nature of their disability residents are unable to hold a key to their room. The reason for this has been agreed and recorded in resident’s plans of care.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 19 The home has a system for identifying, recording and requesting repairs and replacements, which are carried out by the companies maintenance department. The manager confirmed that that most requests are dealt with promptly. Plans to decorate the kitchen are in place and a new cooker has been ordered. There are no radiator covers, however risk assessments are in place and the manager confirmed that covers are to be fitted in residents bedrooms. The home is well decorated and comfortably furnished to provide a homely environment for the residents to live. Domestic style laundry facilities are available in the kitchen separate from the food storage area. All staff are involved in the laundering of residents clothes. Residents are encouraged to help were they are able. The home is spacious, residents’ have their own rooms and there is a small rear, private garden. The home was found to be clean and hygienic throughout both visits with no offensive odours noted in any area. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 20 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): Standards 31,32,34,35,36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited following the correct procedures. The staff team are sufficient in numbers, are involved in the training programme and have clear lines of responsibility. EVIDENCE: Three staff files viewed demonstrated the correct procedures are followed prior to employment to ensure the safety of the residents. Criminal Record Bureau checks are in place and two written references. An induction programme and detailed information on the care needs of the residents ensure the staff are equipped to carry out their roles. During the first visit the manager was on annual leave and the staff on duty demonstrated a clear knowledge of the care required for the residents and had access to the information required for the inspection. Staff spoken with are confident in their roles and were very aware of their responsibilities and actions during the absence of the manager. Comments include: “We are aware of what to do as we have all the policies and procedures to follow”. “We have detailed information on the care needs of the residents”.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 21 “There is always a duty manager should we need support and any incidents are responded to quickly”. Sufficient staff were on duty at both visits to meet the needs of the residents. Two staff provide duty daytime and one nighttime. Staff were observed interacting well with residents. They showed that they have good knowledge and understanding of each resident needs and were patient and caring in their approach. Staff responded to residents in a sensitive and flexible manner. A staff training programme is in place and is ongoing. Training records and staff spoken with confirmed that this is in place. Some staff have completed all the statutory training required and those who require an update are on the list for the next batch of training to be held. This was discussed with the manager during the visit who confirmed that the training will be updated for all staff as soon as possible to ensure they are trained to carry out their roles. All staff receive an induction programme, which is covered over a three months period and the manager assesses their competency. Staff spoken with confirmed their understanding of the abuse procedures, however they would benefit from training in this area. This is recommended within this report and is included in the above section on Concerns, complaints and protection. Two of the staff group of eight are trained in NVQ and the manager confirmed that two staff are taking NVQ Level 2 and three staff are to enrol this month. A recommendation is made for this to be ongoing to obtain the National Minimum Standards of 50 of staff qualified in this area. Staff spoken with confirmed that supervision and regular staff meetings take place. Comments form staff spoken with include: “We get lots of support”. “Supervision and meetings keep us up to date”. “We are a good team and Joan is always there for support”. Staff also said that discussions between the manager and other members of the staff team take place daily in the form of handovers, this is in addition to regular staff meeting. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 22 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): Standards 37, 38,39, 40, 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is organised and well run by an experienced, qualified manager. The home has a positive, inclusive and open atmosphere, which meets the needs of the residents accommodated. EVIDENCE: The manager, Joan Haslett is qualified and experienced and demonstrated a clear understanding of the needs of the client group for which she provides a service. She continually aims to improve their quality of life at all times. Discussion with the manager demonstrated this and improvements in residents daily lives have been made by the strategies which have been put in place to deal with difficult behaviour. The manager has a clear understanding of equality and diversity and demonstrated this in the way the home is run in the best interest of the residents. The residents were observed to be relaxed and comfortable in their environment and interacted well with the staff on duty during the two visits.
Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 23 There are clear lines of communication and this was evidenced by discussion with staff and viewing of the records. Staff spoken with were very positive regarding the support, supervision and guidance provided by the manager and demonstrated a clear understanding of their roles and responsibilities. The manager communicates well with staff and provides regular supervision and meetings to ensure that they are appropriately supported and fully aware of their roles and responsibilities. Quality monitoring of the service takes place via monthly Regulation 26 visits to the home. A Quality Network team involves representatives from all involved in the residents’ care and meets regularly to discuss residents’ rights, outcomes and new developments. A parent of one of the residents is a representative on the board of trustees. Policies and procedures are in place and staff at the home confirmed their knowledge and access of these. A training programme is in place for all staff and this is ongoing. The manager confirmed that staff at the home are to be included in all updates to ensure they are equipped with the skills to carry out their roles. Fire procedures and records are kept up to date and records viewed confirmed this. Regular checks and drills are conducted to ensure residents safety. The manager conducts a monthly fire safety checklist. All certificates for services, such as gas are up to date. All accidents and incidents are recorded. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 24 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 4 2 4 3 X 4 X 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 3 4 4 3 4 X 3 X Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA35 YA23 Good Practice Recommendations NVQ training for staff should continue to reach the standard of 50 . Training in the protection of vulnerable adults should be provided for all staff. Mount Avenue, 12 DS0000005226.V335375.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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
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