Inspection on 06/09/05 for Park Avenue

This inspection was carried out on 6th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Park Avenue 24/02/09

Park Avenue 09/10/06

Park Avenue 05/04/05

Park Avenue 26/10/04

Park Avenue 11/06/04

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

CARE HOME ADULTS 18-65 Park Avenue 74 Alexandra Road Farnborough Hampshire GU14 6DD Lead Inspector Isolina Reilly Unannounced 6 September 2005 10:15 a.m. 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. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Park Avenue Address 74 Alexandra Road Farnborough Hampshire GU14 6DD 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) 01252 547882 Mr Lawrence Alexander Mr Lawrence Alexander CRH 12 Category(ies) of MD Mental disorder registration, with number of places Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service users are not to be admitted under the age of 18 years. Date of last inspection 5th April 2005 Brief Description of the Service: Park Avenue provides care for up to twelve male and female younger adults with mental health disabilities and associated behavioural support needs between the ages of 18 to 65 years. Mr and Mrs Alexander own the home and Mr Lawrence Alexander is the registered manager and is supported by a deputy manager. Mr And Mrs Alexander own the ‘Park Group’ of services that consist of Park View, Park Way and Park Avenue homes and an ‘outreach service’. The home is located in Farnborough with easy access to local shops and other amenities. The home is on a main bus route.The building is a three-storey domestic detached house built in the late 1990’s, comprising of twelve single bedrooms one with en-suite. One of the single rooms provides an independent flat facility on the second floor. The home’s communal space comprises of one lounge and separate dining room, a conservatory area and a further conservatory next door at Park Way provides a smoking area. There is a mature garden laid mainly to lawn and parking is available at the rear of the premises. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. On the day of this unannounced visit the opportunity was taken to look around the home, view records and talk to service users and staff. Most of the service users were seen during the inspection and several were spoken with. Several staff were also spoken with. The home has supplied extra written information for this inspection prior to the visit. This report should be read with this year’s previous inspection report completed on 5th April 2005. What the service does well: What has improved since the last inspection? What they could do better: The home is looking at increasing the number of staff on duty at weekends. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 6 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. Park Avenue H54 S12056 Park Avenue v246437 060905.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 Park Avenue H54 S12056 Park Avenue v246437 060905.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) Standard 2 was assessed and met during this year’s previous inspection. EVIDENCE: Park Avenue H54 S12056 Park Avenue v246437 060905.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) Standards 6, 7 and 9 were assessed and met during this year’s previous inspection. EVIDENCE: Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 10 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) Standards 12, 13, 15, 16 and 17 were assessed and met during this year’s previous inspection. EVIDENCE: Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 11 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) 20 The systems for the administration of medication are good with clear and comprehensive arrangements being in place to ensure service users medication needs are met. Standards 18 and 19 were assessed and met during this year’s previous inspection. EVIDENCE: The staff spoken with confirmed that service users who self-administer are regularly risk assessed and monitored to ensure that they are safe to do so and understand the importance of the medication they are taking. This was reflected in the records sampled. The staff were observed and discussed with the inspector good medication administration practices that are reflected in the homes policy and procedures that were briefly sampled. The medication receipt, administration and disposal records were seen by the inspector and found to be satisfactory. The manager showed the inspector the home’s medication storage cupboard that was clean with medication stored correctly in date and in sufficient quantities. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 12 The staff have completed recent training in the ‘safe handling of medication’ and their competency is regularly assessed. Park Avenue H54 S12056 Park Avenue v246437 060905.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) Standards 22 and 23 were assessed and met during this year’s previous inspection. EVIDENCE: Park Avenue H54 S12056 Park Avenue v246437 060905.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 and 30 The home is clean, homely, comfortable and suitable environment for the service users. The standard of the décor within the home is very good with evidence of improvements through maintenance and future planning. EVIDENCE: The service users stated that the home is looking nice and fresh from the recent painting. The staff confirmed that the rooms are regularly decorated. They like the home and all were very happy with their rooms. Three of the service users stated that they help with the cleaning of the home and have certain tasks they do weekly like vacuuming and polishing. They feel the home is always clean and mostly tidy. Since the last inspection, the lounge sofas have been replaced, to new beds have been replaced and new bedroom furniture in one bedroom. The deputy manager confirmed that the service users and staff were fully involved in designing the new replacement kitchen that includes two ovens and hobs. The inspector was able to see the delivered new kitchen that is awaiting fitting. The owners are in the process of securing three quotes for fitting the new kitchen. The service users and staff spoken with confirmed this. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 15 The inspector was able to look around the home and viewed most of the bedrooms. The Environmental Health Officer last visited the home in June 2004 and the home had been awarded a four star rated certificate that was displayed at main entrance of the home. During the tour of the home the inspector noticed that all the communal hand sinks have liquid soap for washing hands and disposable paper towels. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 16 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) 33 The home’s recruitment procedures have been fully implemented since the last inspection. There has been an improvement in the staff level during the working week ensuring that the level staff on duty does not put the service users at risk. However, the improvement is spasmodic and the home is working towards improving this. EVIDENCE: On the last inspection, the staffing levels and shift patterns were discussed to ensure that sufficient staff are on duty at the most busy times of the day. The duty rota was seen on this visit for the months of August, September and October 2005. Since the last inspection the number of staff on duty during the week has improved ensure that one staff member is not left on their own. The staff duty rotas sampled also confirmed this. The staff spoken with and deputy manager confirmed that this had had a positive impact with managing the weekday shifts. The staff spoken with confirmed that staffing levels at weekend in general had improved but there were still the odd time when one staff member is left at the home. The rotas showed that there were times when only one member of staff is working on two out of nine weekends. This was discussed with the deputy Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 17 manager and member of the management team who are looking to improve the staffing levels for all weekends. The deputy manager and a member of the management team showed the inspector a tool that identifies the number of service users, level of care interaction required at any given time. This will be undertaken as a risk assessment to help with identifying the necessary staff levels. The home is due to pilot this new tool to help with staffing levels. The service users spoken with said that there was always enough staff to look after them and that they felt safe. Since the last inspection, the home has fully implemented the home’s recruitment process and ensured that the staff employed since April 2005 have the necessary checks undertaken. One new staff file was sampled and found that two reference and a ‘protection of vulnerable adults’ (POVA) check. The home has met the requirement raised at the previous inspection. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 18 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) 39 The home has excellent systems in place for self-monitoring, annual review and development. The service users views are part of the home’s development process and annual review. EVIDENCE: The inspector was able to sample June 2005 quality audit findings that are informing the development of the home operating plan for 2006. The quality audit was found to be systematic and comprehensive including all aspects of the service. The action plans reflected findings from the audit. The service users spoken with all stated that they had recently completed a questionnaire regarding their opinions on how the home is run. These questionnaires were sampled and a summary of the finding was available. The service users summary concluded that the service users had confidence in the staff, felt they were understood and activities provided were good. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 19 The staff spoken with also confirmed that they had completed a quality questionnaire and that a summary of the outcomes was also available. The summary concluded that staff are happy in the workplace and feel well supported. The deputy manager confirmed that the quality assurance questionnaires for relatives, friends and professionals are in the process of being typed out and will be made available. Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 2 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park Avenue Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 21 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 33 Regulation 18(1)(a) Requirement The home must have sufficient staff on duty at all times to the needs of service users including weekends. Timescale for action 01/10/05 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 Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 22 Commission for Social Care Inspection 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Park Avenue H54 S12056 Park Avenue v246437 060905.doc Version 1.40 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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