Inspection on 25/01/07 for The Avenue

This inspection was carried out on 25th January 2007.

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 Avenue 25/02/10

The Avenue 26/10/09

The Avenue 28/04/09

The Avenue 20/06/07

The Avenue 20/03/06

The Avenue 18/10/05

The Avenue 22/02/05

The Avenue 17/05/04

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 Avenue 6 The Avenue Keynsham Bath & N E Somerset BS31 2BU Lead Inspector Sarah Webb Key Unannounced Inspection 25th January 2007 09:45a The Avenue DS0000008167.V328535.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 The Avenue DS0000008167.V328535.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. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Avenue Address 6 The Avenue Keynsham Bath & N E Somerset BS31 2BU 0117 9864700 0117 9862524 mfh@netgates.co.uk 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) Keynsham & District Mencap Family Home Mrs Helen Barbara Hill Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 8 persons aged 19 - 64 requiring personal care only May accommodate one named person aged 65 years and over. Will revert when named person leaves. 20th March 2006 Date of last inspection Brief Description of the Service: The avenue is a large four storey, semi-detached property situated in Keynsham. It provide accommodation for eight people aged between the ages of 18 and 64 years of age who have a learning disability. One person is over the age of 64 and there is a specific condition of registration in place for this person. The house has a basement flat that provides accommodation by way of a self contained living area. This comprises of two bedrooms for two residents, a bathroom and a small kitchen. The first and second floor of the property provides accommodation for six residents. The home has secured planning permission to extend the ground floor to provide an accessible bathroom. The home is within easy access of local amenities that include a leisure centre, shops and park. There are accessible transport routes to both Bath and Bristol by both bus and train. There is also a mini bus for residents to use. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection with the focus on reviewing the progress of the requirements and recommendations from the unannounced visit in March 2006 and in assessing the key standards of the National Minimum Standards. The home has demonstrated compliance in meeting all but one of the requirements and recommendations from the previous inspection. This is an environmental issue that is being dealt with when the planned extension of the property begins. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at The Avenue thus meeting a requirement from the previous inspection. The inspection was conducted over 6.5 hours. The inspector had an opportunity to meet with four of the eight residents, four members of staff, and the manager. Residents were observed in preparing for external activities; two residents spoken with said they were happy with the support offered by staff. Staff identified that the home has good communication and management systems in place; one staff member said she could not think of any improvements that could be made. There are no requirements through this inspection What the service does well: The majority of residents have lived at the home for many years and regard this as their family home. Residents are well supported by caring staff and they are provided with an individualised service; if their needs change this is followed through appropriate channels. Residents are also supported by to live a varied and fulfilling life in the home and local community. The home demonstrates good working relationships with other professionals through a multidisciplinary approach. The home has effective systems in place for both staff and residents to access relevant information. The home has effective quality monitoring systems in place in order to seek the views of residents, families and other agencies. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 6 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. The Avenue DS0000008167.V328535.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 The Avenue DS0000008167.V328535.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, 3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessed needs of residents are met to enable an effective admission and ongoing provision of care in line with contractual obligations. EVIDENCE: There have been no new residents admitted to the home since the last inspection. All eight residents living at the Avenue, bar 1 person, are a long established group having lived at the home for many years. Residents were observed being supported by caring and understanding staff. It was evident that staff have built good relationships with individuals and this was demonstrated through the staffs’ warm and sensitive approach when residents and staff were together. Residents were relaxed and comfortable in the company of the staff. Documentation in place evidenced that all residents are funded by the local authority and had been admitted to the home through the care management process. Examination of residents care plans identified that residents changing needs are monitored through regular reviews and updates. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 9 Since the last inspection, two residents have undergone specific assessments that have identified areas of need and development; another person is also in the process of assessment through another specialist service. Records examined indicated that staff are supporting these residents following advice from the local Community Learning Disability Team. Through discussion with the manager and staff and examination of records it was identified that the home is making good progress in meeting the needs of an individual; feedback from specialist services was positive, as were the findings from surveys received by professionals who support residents and staff. They identified that they view the care offered by staff to residents as good and that the home has good working relationships with external agencies. License agreements in place set the terms and conditions of residents stay. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. Residents care plans set out in detail the action needed to be taken by staff to ensure all aspects of their health, personal and social care needs are met. Residents changing needs are monitored through regular review of care plans. Residents are supported in making decisions about their lifestyles and also in taking calculated risks in order that they pursue an independent life. EVIDENCE: The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 11 The home operates a key working system whereby each resident has a named member of staff who plays a key role in co-ordinating the services they receive. Examination of four residents care plans identified information relating to personnel details, health, independence training including personal and living skills programmes, social interaction, and money management. The care plans also addressed residents’ psychological needs, and stated how to respond and support individuals if distressed. Residents meet on a monthly basis with their key worker to review all aspects of their care plan; those care plans examined had been reviewed on a regular basis. The home has also started implementing person centred planning meetings. These are facilitated through an external agency. The manager is involved locally with a specific group to look at how person centred planning is delivered; she also facilitates those person centred plans of residents not living at the home. Residents are encouraged to make differing decisions about their lifestyle including choice of food to attending various activities and in the routines of the home. Two residents said that they were ‘supported in making decisions’ by staff and that processes such as house meetings were a good forum to discuss issues. It was also identified that residents are actively encouraged to take part in attending local advocacy network meetings that are facilitated by an external agency. These are held bi monthly and discussions are centred on what people need. Residents are supported to take risks safely in their daily lives. There were detailed written risk assessments, which helped to demonstrate actions are taken to ensure the home is safe for residents and staff. Risk assessments also demonstrated residents are encouraged to live an independent and fulfilling life and take part in activities away from the home. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers opportunities for individuals to take part in social and educational opportunities in order to enhance their lifestyle. The home supports and maintains residents with their personal and family relationships. The meals in the home offer variety and encourage residents to be aware of healthy eating options. Residents are encouraged and supported with their independence through the daily routines of the home. EVIDENCE: Examination of residents’ care files identified the differing activities individuals attend included paid work, work placements, day services, and college The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 13 courses. It was evident that residents have access to meaningful opportunities in order to promote their own individual lifestyles. One person spoken with said they were in full time employment, but also did some voluntary work in a hospital. Another person also explained about their work placements at a school, a supermarket and older persons care home. They said they travelled independently and enjoyed their work. All residents also access the local community for shopping trips, and attend various leisure activities; these include swimming, aromatherapy and reflexology. On the day of the inspection two residents returned from a regular horseriding trip. The manager said a resident had recently taken part in an audition to form a rock band. The resident verified this and said they had enjoyed it very much. Photographs of a New years party held at the home identified that the manager and staff are committed to ensuring that the ethos of the home is one of a ‘family’ home and that residents experience the same activities and lifestyle as other families. The photographs showed friends, relatives, neighbours, staff and residents enjoying a celebratory night together. Individuals are supported with maintaining friendships and contact with families. The staff have known the residents relatives for a long time and promote ongoing communication with them. The manager said that during the summer the home staged an auction and raised funds to support residents with their holidays. The residents often choose to go on holiday together with last year being no exception. Everyone went to Spain during the summer and also to a ‘turkey and tinsel’ weekend prior to Christmas. Some individuals who attend a local social group also went away for another week to Truro whilst others spent a week sightseeing in London. The residents are involved in the daily routines of the home. Household rotas in the kitchen identified tasks that are shared. Everyone has a turn in preparing an evening meal with support from staff. Menus are decided together and a record is kept of meals offered. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead healthy lifestyles with their healthcare and personal needs being monitored well. The home operates a robust medication system ensuring the safety of the service users. Residents’ benefit from robust measures relating to the administration of medication in order to ensure their health, welfare and safety. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Examination of residents’ healthcare records evidenced that individuals’ physical and mental healthcare needs are met through regular reviews of medication and support from appropriate professionals. Care files also included information that demonstrated residents have access to the GP dentist, optician and other health related agencies. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 15 The home are advised through specialist services from the local Community Learning Difficulty Team. A Speech and Language specialist has advised staff in the risks of residents choking, and how they should be supporting individuals. Staff also support individuals in wax management programmes through advice from specialist services. One resident has undergone 2 specific operations that have been successful; the manager said that this has impinged positively on their lifestyle. The manager said the home is working with a local community facility in producing health action plans for all residents and in providing opportunities to access exercise equipment. This in now to progress to include cooking sessions also linking to health action plans. Care files identified that the home encourages individuals to be independent with their personal needs but also help residents to maintain skills. A manual handling risk assessment was in place for an individual relating to all areas of their mobility and how they should be supported with their personal care including transfers, equipment to be used and method. The home has a policy and procedure for the administration of medication, including a homely remedies policy. These outline the protocols for the administration, recording, ordering, disposal and self-medication processes. It was evident through the observation of records that the home has appropriate systems in place for the safe administration of medication. Medication is administered through the Boots monitored dosage system, and is kept secure. All residents sign for their medication, which in turn is countersigned by a member of staff. Records held were well maintained. Senior staff complete a college course in the safe practice of administering medication whilst all the staff team are trained through Boots pharmacy in the Medication Administration Record. Risk assessments had been carried out for those supported with their medication and for those who self medicate There are appropriate arrangements in place for the administration of medication when residents take social leave. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. Residents benefit from robust systems for complaints and protection and can be confident that they will be listened to and that they will be protected from abuse. EVIDENCE: The home has a formal complaints procedure; residents have been given an accessible copy of the procedure explaining how people can complain; this also includes appropriate contacts and timescales to respond to any complaint. There is also a complaints policy and procedure displayed. There have been no recorded complaints since the last inspection. Two residents spoken said they were happy living at the home and had no complaints. They said they would to go the manager if they had any concerns. The home also convenes house meetings in order to discuss differing issues that may be raised. There are policies and procedures in place relating to the issue of protection of vulnerable adults from abuse. Training records indicated that staff have attended training in the protection of vulnerable adults; an update is booked in the near future for all staff to attend either ‘alerters’ or ‘investigators’ training through the local council. There are facilities for the safekeeping of cash and valuables at the home. All individual financial procedures are recorded in residents main file and kept secure. Residents sign for their personal allowance, which is countersigned by a member of staff; they also collect their monies, independently, and if The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 17 needed, supported by staff. Financial sheets record savings details, and payment for board and lodging. There are control measures in place for staff to check monies. Residents are encouraged to save money towards holidays and seasonal events through a money saving programme. Since the last inspection, there have been no regulation 37 notifications received from the home in relation to behaviours that may challenge. It was evident through observation and discussion with staff and the manager that an individual has made good progress. Feedback from specialist services involved in their care was positive in the way the home has dealt with challenging situations and documentation indicated strategies in place in supporting them. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a homely, comfortable and clean environment. Residents’ benefit from the homes response to their changing physical needs with planning towards improving the accessibility of the environment. EVIDENCE: The home is a large, four storey, semi -detached stone-built, property situated in the community of Keynsham. The external appearance of the home is in keeping with neighbouring properties. Local amenities include a leisure centre, shops and a park. There are accessible transport routes to Bath, Bristol and other local areas. The home felt `light’ and airy in communal rooms and the environment was clean, tidy and free from odour. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 19 Plans for the property to be extended have been submitted; there have been no objections from the neighbours. Plans are in line with the changing needs of residents and include a ground floor accessible bathroom and an external lift to the front door. A ground floor sleep in room/office is also integrated in the plans. The manager said the work has gone out to tender and she is to meet with the architect and builder. Installation of a new boiler that services the whole property is also to be included within the changes. A requirement is unmet in the repair of cracks in the concrete of steps leading to the front entrance. Discussion with the manager highlighted that the planned changes will include improvements to the front entrance and that this is an area that will be dealt with when the planned extension of the property begins. Due to the arrangements for the building works progressing this current unmet requirement has therefore been withdraw. The home has looked ahead to the future needs of residents and has also installed a new stair chair. Although there are currently no residents who use this facility, elderly families can now visit their relative in their room privately. The home has fitted grab rails to areas of the home in order to maintain individuals independence and support differing mobility needs. Since the last inspection the basement flat has a new toilet, sink, and flooring. A bedroom in this area is soon to have windows replaced and to be decorated. A new fire alarm panel has also been fitted due to the effects from an electrical storm. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent, qualified staff. The training needs of staff are well met and appropriate training related to individuals needs is offered in order to support residents effectively. Staff receive regular supervision which helps staff to support individuals consistently. EVIDENCE: There are seven staff employed at the home. The team are long standing with the majority having worked together for many years. The home does not use agency staff. A staff member spoken to was clear about their role and responsibilities and gave examples of how they supported the residents. There are control measures in place for staff to check monies. Service users are encouraged to save money towards holidays and seasonal events through a money saving programme. The staff duty record for shifts worked for the current month was inspected to review the number of staff on duty to support residents with their needs. It is The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 21 evident that staff work flexibly in supporting individuals. This was demonstrated through 2 residents being supported during the day with differing activities. All meetings, activities, and appointments are recorded on the rota and taken into account. There is a minimum of one member of staff on duty for a night shift as from 11.00 pm and between two and three staff on duty during core hours during the day between 7.30am and 3.30pm to work closely supporting residents both in and out of the home. Two staff are on duty as from 3.30pm to 11pm. Staff meetings take place two monthly. It was evident through observation and discussion with staff, that the team operates effectively and are supportive of each other communicating openly. All staff have completed National Vocational Qualification Level 3. This is good practice and to be commended. The home is supporting a volunteer to complete their National Vocational Qualification level 2 through an external assessor. The home has a staff training and development policy and follows the homes policy and procedures in identifying staff training needs, delivery and review of training. From discussions with staff and observation of staff training records it was evident that there is a rolling programme of health and safety training including manual handling, fire, food hygiene and first aid. Training records also identified staff have had access to other training courses. These included training in working with people who have Aspergers, Intensive Interaction, the care of medicines, health and safety, Makaton, and risk assessing. Staff spoken with stated that the manager provides them with regular structured supervision sessions to support them in their work. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well run home with efficient systems in place. Residents’ benefit from an effective quality monitoring system in place in order to seek their views, and others involved with their care, and act on the findings. Residents’ rights and best interests are safeguarded by appropriate record keeping. There are procedures and protocols in place in order to ensure the health, safety and welfare of both residents and staff. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has been in post since 1994 and has a number of formal qualifications. She demonstrated a clear awareness of both her responsibilities and ability as a registered manager under the Care Standards Act to manage the home effectively. The manager is part of the Bath and North East Somerset Steering group in relation to person centred planning and facilitates residents person centred plans external to the home. She said she sees this as part of her personal development. Since the last inspection she has attended training in food hygiene, first aid, consent, and person centred planning. The home carries out an annual quality assurance survey annually in which residents, their families, and other agencies are consulted. The manager has involved an external advocacy service to facilitate the completion of accessible questionnaires by residents. This is good practice. Surveys had also been received from both families and many of the agencies involved in supporting the residents; these included specialist services from the local Community Learning Difficulty Team, medical professionals, social workers, and all those supporting the residents with external social opportunities. All of the surveys examined provided a positive response in how the home supports residents in all areas of their care. A requirement has been met to inform the Commission of the results of the previous annual quality monitoring review. Records are kept in the office ensuring residents confidential information is held securely but allowing residents to have access to their records. All the records inspected were well maintained, up to date and in order. Residents had signed records where relevant. Other records have been referred to elsewhere in this report, and demonstrate well-organised management in the home. Examination of the fire log indicated that all staff have received annual fire training and have been involved in fire drills thereby meeting a requirement to include all staff in regular fire drills. A fire risk assessment had been carried out and fire maintenance records indicated that fire equipment is inspected on a regular basis by both staff and contactors. There was a current certificate of insurance displayed in the home. The home keeps a record of accidents and incidents and keeps the Commission informed through regulation 37 notifications of the same. The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 24 The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 25 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 3 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 x 35 3 36 3 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 3 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 4 x 3 3 x The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 26 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. Refer to Standard Good Practice Recommendations The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 The Avenue DS0000008167.V328535.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!