Inspection on 06/12/05 for Tavistock Avenue (5).

This inspection was carried out on 6th December 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tavistock Avenue (5). 29/05/07

Tavistock Avenue (5). 12/06/06

Tavistock Avenue (5). 18/08/05

Tavistock Avenue (5). 07/12/04

Tavistock Avenue (5). 27/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Tavistock Avenue (5) 5 Tavistock Avenue St Albans Hertfordshire AL1 2NQ Lead Inspector Mrs Jan Sheppard Unannounced Inspection 6th December 2005 10:00 Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Tavistock Avenue (5) Address 5 Tavistock Avenue St Albans Hertfordshire AL1 2NQ 01727 843545 01727 843545 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) Cherry Tree Housing Association Mrs Janet Gale Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: The home is a two storey semi-detached house in a residential area of St. Albans. It is owned by Cherry Tree Housing Association and is situated close to the city centre with easy access to public transport. The ground floor comprises a lounge, a combined kitchen dining room, one bedroom, an assisted shower room and a laundry room. Two bedrooms, a bathroom and a staff office are located on the first floor. The home provides full care services in a safe and homely environment for three service users who all have learning disabilities. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection that took place over one day during which two of the service users currently resident in the home and all the staff on duty were spoken with. Discussions were also had with the Associations Director of Care who visited the home during the time of this inspection. The comments in this report reflect the findings made by the inspector during that day and also take account of information gathered from the pre-inspection questionnaires recently completed by the homes manager and the residents. Not all of the standards were examined during this inspection as they were all covered during the previous visit on 18th August last, to which reference may be made. There are no unmet requirements from the last inspection. One requirement is made following this inspection. The home continues to offer a caring and very homely environment for its residents. What the service does well: What has improved since the last inspection? Since the last inspection a number of improvements and changes to the decorations and internal fabric of the home have been made and a number of new pieces of equipment purchased. Residents have been encouraged to generally de- clutter and rearrange the storage of some of their possessions in their bedrooms, which has given them more personal space. A more resident inclusive format for their consultations has been introduced with the aim to enable the residents to fully own the organisation and running of their home. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 6 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. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: This section was not inspected, as there have been no new residents have been admitted to the home since the last inspection. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): 6,7 and 9 The home maintains detailed individual care plans for each resident, which reflect his or her personal needs and aspirations. EVIDENCE: The care plans examined evidenced that all were maintained up to date and that they gave good detail as to the care needs of the residents and how these needs should be met. Up to date risk assessments were also noted. Multidisciplinary meetings to review these plans had been held for all residents since the last inspection. The records for one resident gave good evidence as to the gradual improvements being made with social skills how these were planned and encouraged by the staff and with appropriate risk assessments being undertaken. During the time of this inspection the staff were heard to be consulting with the residents concerning their choices for the days activity and for their choices for lunch. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): 11,12,13,15 and 17. Each resident had an individually planned activity and educational programme arranged to meet their needs and promote skills and interests. Recent changes and cancellation of some of these activities by their external providers have resulted in the need for review of these programmes to ensure that these needs of the residents are being fully met. The home offers a nutritious and varied menu chosen by the residents and supervised by a dietician, which offers fresh ingredients and home cooking on a daily basis. EVIDENCE: Whilst the residents do still have opportunities for personal development these have recently been diminished due to external factors beyond the influence of the home. The manager discussed with the inspector the various avenues that are being explored so that alternative programmes can be arranged to plug the gaps left by these changes. The special needs of one particular resident who has previously refused all group based activities were discussed and the assistance of her social services representative has been sought. A requirement is made. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 11 All the residents have regular contact with their families or family friends and make regular visits, and staying visits, to see them. All were involved with the recent review meetings and the manager discussed with the inspector various new ways in which she is encouraging the family’s further involvement with the home. The manager also discussed her plans to increase the range of weekend community based activities and how staffing of these should be met. During the summer all the residents enjoyed a self-catering holiday at Butlins in Bognor and happy photos of this were shown to the inspector by the residents. The homes records evidenced that good attention is given to celebrating the residents birthdays, for one occasion the whole home went for a celebratory meal at an Italian restaurant and for another resident a special meal was prepared in the home to which several of her friends were invited. The dietician continues to visit the home regularly and monitors the weight and fluid intake of one resident and the reducing diet of another resident could be evidenced from the records kept. One resident is being assisted by staff to increase her food preparation skills. All the residents help the staff with the planning of the weekly menus with the compiling of the weekly shopping list and with the purchasing of the food. The residents were seen to help themselves from the bowl of fresh fruit in the dining area and fresh vegetables were seen ready for preparation for the evening meal. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): 18 and 20 The standard of care offered in this home is good meeting the physical and emotional needs of the residents. EVIDENCE: Personal care was observed to be being given in a calm kindly and unhurried manner by staff who were seen to anticipate the service users needs and yet delivered their care in a manner that enabled them to have as much responsibility for meeting their own care needs as it was safely possible for them to do. There have been no changes to the homes medication storage and administration systems since the last inspection. Staff who administer medication have received the appropriate training and the manager makes regular checks as to the accuracy of the MAR sheet recording. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23. The home has the required complaints policy and procedures, a copy of which has been given to all residents and where possible also to their relatives and families. The home has policies and procedures concerning Adult Protection and Whistle Blowing, which follow the guidelines given in the Hertfordshire County Council Adult Protection Joint Agency procedures. EVIDENCE: There have been no complaints nor any incidents concerning Adult protection since the last inspection. The staff spoken with demonstrated a sound understanding of adult Protection and of the procedures that they should follow if ever any incident were bought to their attention. The homes training records evidenced that staff had attending training subject during May 2005. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 the following standard(s): 24 and 30 Number 5 Tavistock Avenue provides a homely safe and comfortable environment where the accommodation meets the residents physical and social needs and the facilities provided are suitable to enable the appropriate care to meet their assessed needs to be given. EVIDENCE: On the day of this unannounced inspection the home was found to be clean and tidy and was very attractively decorated for Christmas. Since the last inspection the home has been redecorated externally and plans to ramp the front door were shown to the inspector. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 The home continues to retain a stable experienced and well qualified staff group. Staff training is given high priority. EVIDENCE: The homes records evidenced that monthly staff supervision is given and that staff all have an annual appraisal. All staff have a training needs profile and the training offered by the home continues to be adequate to meet these needs. Since the last inspection courses on Fire Safety, staff supervision, Respecting Diversity, Food Hygiene, Medication Administration, Epilepsy Care and Adult Protection have been attended or have attendance planned in the near future. The home far exceeds the required 50 of staff having the NVQ level 2 qualification. All new carers are expected to study for this level of qualification and many also hold the level 3.The manager is part way through the NVQ level 4 Management and registered managers award. The staff were seen to be working well together as a team with a very good spirit of co-operation. As no new staff have been appointed since the last inspection it was not possible to examine recent recruitment records. However the home has the correct recruitment policies and procedures, which should ensure the safety of the residents. The manager confirmed that being a small home where sometimes a single member of staff only will be on duty this precluded any new appointment being commenced until the full CRB checks had been completed. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 16 Detailed records relating to the monthly staff meetings evidenced that these were well-attended meetings with good participation by all the staff. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. The home is well run by a stable experienced and well qualified staff group many of whom have dedicatedly worked with these residents for many years and have a sound knowledge of how to meet heir needs. EVIDENCE: The new manager, in post for six months, has now had time to fully settle into the home and to review the manner in which it operates. Various small changes these to improve the quality of care for the residents have been successfully completed and other plans are being discussed with the staff and residents. One resident told the inspector that,” all the staff and the new manager are easy to talk to and are always asking us for our views”. She added that she would give her views anyway even if they were not asked for!. The records examined concerning fire procedures evidenced that the appropriate checks precautions and tests of equipment were being carried out and that residents were all now responding promptly to these. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 18 Staff and residents appeared to have a good awareness of issues relating to their own health and safety and appropriate risk assessments were seen to be maintained up to date. Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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 x x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tavistock Avenue (5) Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x DS0000019561.V270401.R01.S.doc Version 5.0 Page 20 no 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 YA11 Regulation 15(1) 16(4) Requirement The day care programmes for all the residents must be reviewed and new activities identified so as to fully meet their current needs. Timescale for action 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Tavistock Avenue (5) DS0000019561.V270401.R01.S.doc Version 5.0 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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