Inspection on 21/05/08 for South Avenue, 1

This inspection was carried out on 21st May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

South Avenue, 1 20/08/09

South Avenue, 1 16/04/07

South Avenue, 1 20/11/06

South Avenue, 1 06/12/05

South Avenue, 1 03/02/05

South Avenue, 1 24/08/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 South Avenue, 1 1 South Avenue Chellaston Derby DE73 6RS Lead Inspector Vanessa Davies Unannounced Inspection 21st April 2008 09:00 South Avenue, 1 DS0000048582.V362741.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 South Avenue, 1 DS0000048582.V362741.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. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Avenue, 1 Address 1 South Avenue Chellaston Derby DE73 6RS 01332 705136 01332 705136 donna.chetwyn@robinia.co.uk www.robinia.co.uk The Robinia Group PLC 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) Miss Donna Michelle Chetwyn Care Home 8 Category(ies) of Learning disability (8) registration, with number of places South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th April 2007 Brief Description of the Service: The home is registered to provide support and accommodation for 8 individuals with learning disabilities between the ages of 18 - 65 years old. The house is situated close to the centre of Chellaston, and within 2 minutes walk to local shops. The house has been furnished to reflect the style of a family home. The home is located on a private road and has a car park at the side of the building, and an enclosed secure garden. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is two star. This means the people who use the service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. In order to prepare for this visit we looked at all the information that we received and asked for, since the last key inspection on 16th April 2007. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people representing a cross section of the care needs of individuals within the home. Discussions were held with those people able to do so. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. Following discussions it was agreed that the people who live in this service would be referred to as ‘service users’ for the purpose of this report. What the service does well: All of the service users files examined held detailed information regarding their needs. Regular reviews ensure that information is kept up to date and any changes are made. Service users and relatives are involved with the review process. Service users are supported and encouraged to make decisions affecting their lives. It was clear that the staff have good positive relationships with the service users and are keen to ensure that they lead full and meaningful lives. One service user said “staff are lovely they help me to see my family who live abroad” another service user said “ I don’t get on with all the staff but I do have my favourites, they’re lovely” Staff work positively with service users, encouraging appropriate social skills to ensure that they are included in the local community. The staff include service users with the preparation of a menu and ensure that choices are offered. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 6 The home has a complaints procedure and the service user spoken with was aware of this. Complaints are recorded, as are the responses to them. The home is well kept and clean, service users rooms are personalised and meet their needs. A confident and competent person who is dedicated to ensuring that the service users lead as independent a life as possible manages the home. 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. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Detailed assessments of need, medical information and the inclusion of service users ensures that needs are highlighted and met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All files examined had a completed assessment prior to admission to the home. The assessments were very detailed and along with the persons history it clearly states the needs the new home would have to meet. There was evidence of a full medical history and a completed health diary. Although the person had not been completely involved, members of the family and social services had been involved in the preparation. The manager has made the file completely user friendly, easy to read and easy to understand. A service user spoken with stated that she had been involved with her assessment and was aware of her file containing information about her, she knew she could read through it if she wanted to but chose not too. She attends reviews but chooses not to stay through it all. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. Positive relations between staff and service users promote independence and assists service users to make choices and decisions affecting their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information provided by the manager states that the home has person centred plans for each individual and this was evident on the day of the visit. All service users are allocated 2 key-workers and both service users spoken with stated the names of their key-workers and the types of things they expected from them. Service users are able to choose the décor in their rooms and be involved with choosing the décor for the home, they have a choice of meals and decide on their activities. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 10 We spoke with two service users, 1 has regular contact with her family and visits them for long holidays, accompanied by a member of staff if she requests. The 2nd service user has regular contact with both parents, she confirmed that it was her choice when to visit. Both stated they go on holiday at least once a year and chose where to go to. They both stated that they were involved with aspects of their life and completed a daily diary with the help of staff. They both have access to their care files and are involved with the preparation of information for a review of care and also attend their reviews to agree or disagree with any outcome or decisions made. It was clear after speaking with the service users that they do have the opportunity to make their own decisions. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. Positive staff relationships, promotion of independence, encouraging choice and decision making helps to ensure that people lead a positive and developing lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the files examined showed evidence of a variety of activities being offered; cinema, shopping, college and MENCAP. All 3 files were very userfriendly and there was evidence of input from the service users. The staff have now started to develop very individual life diaries for each of the service users, these diaries from the beginning show the personality of the person who it is about. Each person has a key-worker with whom he/she can speak with if any issues arise and those spoken with stated that they valued this. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 12 Each of the files had information relating to friendships the service users had, the information included addresses of friends, birthdays and other important dates. One of the service users spoken with felt that staff treated her with respect and offered her as much support as she needed. It was evident on the day of the visit that service users are afforded the opportunity to speak with staff and the manager if they request. One service user had a problem she wanted to discuss with the manager and spent quite a long time discussing it with her, when asked the service user confirmed that she frequently sits down with the manager or her key-worker to discuss any problem she has. One service user had requested her bedroom be redecorated and this has been arranged for when she goes away on holiday. The Manager stated that she has quarterly meetings with the service user, key-workers and relatives. The information provided by the manager prior to inspection is that service users are supported to make decisions that affect their everyday life and this includes making choices about: holidays, contact with family and friends and access to local colleges and the community, in order for this to happen the home has, changed the staff rota to enable more flexibility, this means that staff now work all day as opposed to 2 shifts, and this allows for continuity and stability. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good. Input from a variety of other professionals as necessary ensures that service users holistic needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care files examined evidenced personal support service users may need. The care files have been completely reviewed and are now in an easy to read format, with all need to know information clearly available and easy to find. Assessments and care plans ensured that physical and emotional needs were met. There was evidence of input from a variety of other professionals as necessary and this was confirmed by the service users spoken with. All staff have received personal care training to ensure that privacy and dignity is maintained at all times. The home has a detailed medication policy and staff administering medication have all received appropriate training. All medication is stored, recorded and administered appropriately. Should a service user wish to self-administer an South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 14 appropriate detailed risk assessment would be completed to ensure all risks are highlighted and eliminated as possible. Medication is signed in and out of the home and any PRN needing to be administered is recorded appropriately. It was evident that service users have access to a range of other professionals as necessary. Appointments are made and the necessary support is provided. Relatives are invited to attend, however if they do not attend they are informed of the outcomes. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 15 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): 22,23 Quality in this outcome area is good. A detailed complaints procedure ensures that service users and relatives feel listened to and able to raise any concerns. Appropriate training for staff ensures that service users are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both service users spoken with confirmed that they were aware of how to make a complaint and they also confirmed that they are able to speak with a number of members of staff and know that their issues will be addressed without any repercussions. All service users receive a complaints procedure written in a suitable format. It was evident on the day of the visit that one of the service users was aware of our role and did ask to speak with us. The manager stated that all staff have received training in Safeguarding Adults, there was evidence made available. Staff have a CRB in place prior to starting at the home. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 16 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): 24,30 Quality in this outcome area is good. A clean and tidy home with appropriate security ensures that risks to service users are limited as much as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was in the process of being redecorated and when speaking with one service user she stated that she had asked for her bedroom to be redecorated and the manager confirmed that this had been arranged and would be done when she is on holiday. We toured the home and was invited into one service users room, the room was very personal with books and family photographs around. She confirmed that she had sufficient furniture in the room and was confident that if she needed other furniture she could ask for it and would be listened to. The home has secure well-kept gardens and these are used by the service users. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 17 There are 8 bedrooms all with en-suite facilities and all bedrooms are decorated to the service users preference and made very personal. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 18 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): 32,34,35 Quality in this outcome area is excellent. Staff working with appropriate training and offers of further training ensures that service users are not put at risk of harm and are cared for by staff trained to do so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Nine out of thirteen staff have an NVQ qualification, two have NVQ 2 and seven have NVQ 3. The manager stated that all staff who started after May 04 have completed the Learning Disability Awards Framework (LDAF) standards, with new staff enrolled for completion in 6 months. The workbooks for the LDAF framework have been improved, ensuring that work is completed in faster timescales She also stated that there have been changes within the management structure of the organisation and that they the company employs a regional trainer and national training manager. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 19 All staff have induction as part of their training. Monthly supervisions and annual appraisals take place to discuss amongst other things training and development. All staff have completed mandatory training, in addition to mandatory training the company offers training in Autism, Epilepsy and Makaton. The structure of the training has been redeveloped, providing more training opportunities and at more regular intervals. The company has a training manual (The Pathways) to ensure continuous development for all staff. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 20 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): 37,39,42 Quality in this outcome area is good. A well-qualified and competent manager helps to ensure the home is run in the best interests of the service users and improved monitoring and staff training prevents service users being placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A competent, well-qualified and dedicated person manages the home, she is qualified with NVQ 4 and the Registered Managers Award. All staff and the service users spoken with, spoke very highly about her and were confident that the home was run well whilst she was managing. The home has regular Staff Meetings and staff receive monthly 1:1 supervision with the manager. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 21 The home receives monthly visits as required by Regulation 26. The manager and staff undertake regular fire alarm tests and drills and records are kept. Staff are aware of the need to report any health and safety issue. Staff are experienced and many have worked in the home since it opened 4.5 years ago. The manager has worked at the home since it opened, and has a wide range of experience and knowledge. Regular audits are carried out by the manager, service user surveys and relatives surveys are completed and used to update information. Appropriate staff records are kept and staff receive both mandatory training and other types of training appropriate to the needs of the service users. 7 of the 13 staff hold NVQ 3 and 2 have NVQ 2. The manager has made a number of positive changes within the home, the main change being developing lifestyle diaries for all of the service users, the service users have enjoyed doing this and value it very much, it gives an excellent insight into the lives of the service users and they are very eager to show them to relatives and staff and to continue to develop them further. The manager completed the self assessment form (AQAA) and returned to CSCI within the given timescales, although she completed this well she did not emphasis the positive changes made since the previous inspection particularly the work which has clearly gone into developing the lifestyle books and how excited the service users and staff are about them. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 22 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 X 2 3 3 X 4 X 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 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 Refer to Standard YA2 Good Practice Recommendations The manager should continue to develop service users files. South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 South Avenue, 1 DS0000048582.V362741.R01.S.doc Version 5.2 Page 25 - 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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