Inspection on 29/06/05 for The Ann Coleman Centre

This inspection was carried out on 29th June 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 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

The Ann Coleman Centre 15/03/07

The Ann Coleman Centre 07/12/05

The Ann Coleman Centre 17/02/05

The Ann Coleman Centre 12/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Ann Coleman Centre Ridingleaze Lawrence Weston Bristol BS11 0QE Lead Inspector Helen Taylor Unannounced 29 June 2005 09.30 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. The Ann Coleman Centre Version 1.10 Page 3 SERVICE INFORMATION Name of service The Ann Coleman Centre Address Ridingleaze Lawrence Weston Bristol BS11 0QE 0117 9380155 0117 9380157 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) Avon Autistic Foundation Mr Andrew Coleman PC Care Home 7 Category(ies) of LD Learning Disability (7) registration, with number of places The Ann Coleman Centre Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Andrew Coleman to take effect as Manager from closure of Longcross Date of last inspection 17 February 2005 (Announced) Brief Description of the Service: The Ann Coleman Centre is owned and operated by the Avon Autistic Foundation Ltd, an organisation that specialise in the care of persons who have a diagnosis of autism or asperger syndrome. The centre provides personal care and accommodation for seven persons on the first floor although only six persons are accommodated at the present time. Facilities on the ground floor offer a range of social and educational activities. The property is arranged over two floors. The activity centre is based on the ground floor with a computer room, arts and crafts room and a snoezelon. A large conservatory is used to provide a quiet area for board games. The main kitchen and dining room area are located on the ground floor. Service user provision is located on the first floor and chair lift access is available if required. Each bedroom has en-suite facilities. Communal space consists of two lounges, a kitchen, bathroom and toilet. To the outside of the property there is a paved area with garden furniture. The property is purpose built and all areas are accessible to wheelchair users. The Ann Coleman Centre Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection as part of the annual inspection programme. The purpose of the visit was to review any requirements and recommendations made during the last inspection, and to examine the standard of care provided. Evidence was gathered from a review of records held, consultation with the provider and staff, and through observation of interaction between staff and residents. What the service does well: What has improved since the last inspection? Residents benefit from the improvements made to record keeping and staff have been advised in writing what to do if an error is made. This was in response to a recommendation from the previous inspection. A new system has been developed to ensure staff sign to acknowledge when new procedures or up dated guidelines in relation to policy or practice are implemented. This ensures consistent care and support is provided for residents. A new format has also been developed to prompt staff and provide consistency ensuring all individual rooms are kept clean and well maintained. Residents benefit from a well maintained home, and many areas of the home have been decorated as part of the ongoing maintenance programme. The day programme has been enhanced with the addition of sessions from a keep fit instructor. Special floor equipment has been purchased for use during the sessions. The Ann Coleman Centre Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Ann Coleman Centre Version 1.10 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 The Ann Coleman Centre Version 1.10 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5, Information is available to residents and their representatives to enable an informed choice about service provision. EVIDENCE: A statement of purpose and resident guide are available in the home and provide detailed information on the services provided. Pictorial information has been used in the resident guide to enable access for prospective residents who may have communication difficulties. Admission to the home is through the care management approach and all admissions are on a planned basis. The provider explained a prospective resident who had visited the home, was attending the day centre as a gradual introduction to the services offered. Interactions with the present group of residents would be monitored with a view to offering a permanent placement. This was in line with good practice. Through discussion with staff and a review of the care file information it was evident that comprehensive assessments of need had been undertaken. Detailed care plans covering all areas within the National Minimum Standards were in place for each resident. The Ann Coleman Centre Version 1.10 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9,10. Clear information is held demonstrating individual assessment and changing needs being identified. Social and community activities are tailored to meet specific wishes and abilities, and provide daily variation for the people living in the home. EVIDENCE: Each resident has in place a detailed care plan covering all aspects of daily life. An individual activity programme incorporating activities within the centre and in the community is drawn up within a risk assessment framework. Advice and guidance is sought from relevant professionals, in conjunction with the resident, key worker and family members. From records reviewed and discussion with staff there was evidence of structured activities being organised. The provider stated a keep fit instructor had recently been employed on a sessional basis, and equipment had been purchased for use during the sessions. A staff member stated that the residents were enjoying the new activity. The Ann Coleman Centre Version 1.10 Page 10 One resident attends a local college and is presently studying the Spanish language on one course, and skills towards independence on another. A staff member explained another resident was in the process of investigating appropriate college placements to start in September. A pictorial guide to activities on offer during the weekend period was seen and a staff member confirmed a driver is available for organised trips in the local area. Policies and procedures are in place to ensure staff are aware of the confidential nature of their work. The care files were stored appropriately. The Ann Coleman Centre Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14. The residents benefit from and are supported to participate in a range of leisure and social activities. Relationships with family members are encouraged. EVIDENCE: Activities on offer at the home include: art therapy, keep fit, music therapy, computer technology, craft sessions, and cooking. This is not an exhaustive list. The provider explained there was a plan to introduce pottery making to include glazing in a kiln. Activities in the local community are planned on a regular basis, and residents choices are taken account of when planning excursions. Records reviewed indicated support and encouragement is offered to encourage residents to participate in new experiences. The key workers have individual sessions monthly with each resident to determine their level of satisfaction with services provided, and record any suggestions or concerns they may have. This is consistent with good practice. The Ann Coleman Centre Version 1.10 Page 12 Contact with family and friends is encouraged and recorded in the care file. One staff member explained contact and guidance from relatives was important and recently advice had been sought in relation to the food one resident likes. The staff member was able to demonstrate the parents input had been pivotal in developing a menu suitable to this residents needs and choices. The Ann Coleman Centre Version 1.10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21. The personal and healthcare needs of the residents are monitored effectively and action is taken promptly when concerns arise, so that residents can be confident their needs will be met. EVIDENCE: There have been no accidents or incidents where residents have been taken to the accident and emergency department. Care documentation reviewed provided evidence of clear guidance for staff on how residents wished personal support to be provided. The home consults health professionals to ensure medication is reviewed regularly, and all changes are provided in written form. The health care records were clear and contained information in relation to all health care needs. Regular visits by a psychiatrist who specialises in the needs of persons with autism or aspersers syndrome are also recorded. Staff support is offered for attendance at all health care appointments. A review of the storage and administration of medication revealed no errors. The medication is stored appropriately, and was well organised, and all records were clear and up to date. There are no residents at the home who self medicate; all are supported by staff with this. The Ann Coleman Centre Version 1.10 Page 14 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) These standards were not reviewed on this occasion. EVIDENCE: The Inspector has previously seen the complaints procedure and the service user guide that makes good use of symbols and pictures to encourage residents to talk to staff if anything upsets them. Policies and procedures are in place to ensure residents are protected from any form of abuse. The Ann Coleman Centre Version 1.10 Page 15 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) 24,25,26,27,28,29. The quality of the furniture and fittings in the home is of a very high standard and overall a warm comfortable environment has been created ensuring individual needs are met. EVIDENCE: The location and layout of the home is suitable for its intended purpose. The accommodation is bright, comfortable and well furnished. The property is well maintained and the Inspector had the opportunity to observe the some decoration taking place in the craft room. A tour of the premises provided evidence that residents are encouraged to personalise their rooms, and adaptations have been made through the assessment process to meet individual need. The home was clean and tidy and free from odour at the time of the inspection. The Ann Coleman Centre Version 1.10 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) 31,34,35,36. Appropriately trained staff support the residents, however the home has failed to demonstrate safe recruitment practices are in place to safeguard and protect residents from harm. EVIDENCE: A sample of staffing information held revealed no POVA first or CRB check had been obtained prior to the employment start date for the newest staff member. The provider stated that the staff member was following an induction programme, and was adequately supervised. However the staffing rota viewed did not support this information, as the staff member was not supernumery. The staffing rota did not provide information relating to the managers hours. At the time of the inspection only two staff members were on duty supporting eight residents. The newest staff member was one of them. An immediate requirement has since been issued in relation to the recruitment process. Staff stated that they felt well supported in the home, and supervision and training are offered to develop skills and expertise. One staff member confirmed good progress with the NVQ level 3 award. The provider stated that an external assessor visits weekly to provide support. The Ann Coleman Centre Version 1.10 Page 17 Records reviewed provided evidence of induction and foundation training having taken place. The organisations foundation-training package is being assessed for the purpose of accreditation. External training is organised on a regular basis to cover for example: Fire Awareness, First Aid and Challenging behaviour. This is not an exhaustive list. The Ann Coleman Centre Version 1.10 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) These standards were not assessed on this occasion. EVIDENCE: The Inspector is aware that policies and procedures are in place at the home to safeguard the best interests of the residents, however as discussed earlier in this report the recruitment policy is not being implemented and this report contains a requirement in relation to this. The staffing rota does not provide information about the registered managers hours, or any management support on a day-to-day basis. A requirement for this to be implemented is contained in this report. The Ann Coleman Centre Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 x Standard No 11 12 13 14 15 The Ann Coleman Centre x 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 x x 2 3 x Version 1.10 Page 20 16 17 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x x x x x x The Ann Coleman Centre Version 1.10 Page 21 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. 2. Standard 34 33 Regulation 19. Sch.2 Requirement Timescale for action 8th July 2005 30th July 2005 To obtain in respect of all staff a CRB check prior to the start of employment. Sch.4 (6)e The duty rota to include details 7. of registered maangers hours. 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 The Ann Coleman Centre Version 1.10 Page 22 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 The Ann Coleman Centre Version 1.10 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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