Inspection on 26/10/09 for The Avenue

This inspection was carried out on 26th October 2009.

CQC found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Avenue 25/02/10

The Avenue 28/04/09

The Avenue 20/06/07

The Avenue 25/01/07

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 11/04/2010.

Key inspection report Care homes for adults (18-65 years) Name: Address: The Avenue 6 The Avenue Keynsham Bath & N E Somerset BS31 2BU     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Sarah Webb     Date: 2 7 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 37 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 37 Information about the care home Name of care home: Address: The Avenue 6 The Avenue Keynsham Bath & N E Somerset BS31 2BU 01179864700 01179862524 helen.hill@sovision.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Keynsham & District Mencap Family Home care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is 8 The registered person may provide the following category of service only: Care home only - code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Learning disability (Code LD) Date of last inspection Brief description of the care home The Avenue is a large four storey, semi-detached property situated in Keynsham. It provides accommodation for seven people between the ages of 18 and 64 years of age who have a learning disability. There are some people who are over 64 years who have lived at the home for many years. The house has a basement flat that provides accommodation by way of a selfcontained living area. This comprises of two bedrooms for two people, a bathroom and a small kitchen. The first and second floor of the property provide accommodation for six people. A new wet room, containing a fully accessible toilet and shower, has been installed to meet peoples changing needs. There is also a new staff sleeping-in room and a new office. A basement has been provided for storage space for old records and Care Homes for Adults (18-65 years) Page 4 of 37 Over 65 0 8 0 1 0 5 2 0 0 9 Brief description of the care home other items. The home is within easy access of local amenities that include a leisure centre, shops and park. There are accessible transport routes to Bath and Bristol by both bus and train. Care Homes for Adults (18-65 years) Page 5 of 37 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced Key Inspection carried out by two inspectors over two days. The last Key Inspection of the Avenue was completed on 1st May 2009 following the outcomes of a safeguarding investigation by the local authority. We had planned to inspect the service within six months of the last inspection as the outcomes had been poor. We met with the Registered Manager and a Director on 24th June 2009 for a Service of Concern meeting. At this meeting we asked for an Improvement Plan to be sent to us telling us how the requirements were to be met. A further meeting took place between us, the local authority, and two Directors on 31st July 2009. They were also asked to send an Improvement Plan telling us how they intended to address management issues that had been identified. The pre inspection planning involved reviewing the report of the last Key Inspection, Care Homes for Adults (18-65 years) Page 6 of 37 and the two Improvement Plans we requested. We also looked at the service history that details all other contact we have had with or about the home. We spoke with the Registered Manager, three staff and a new relief worker. We also spoke with three people living at the home individually, and without staff support. We have received surveys from all the people living at the home. An advocacy service has helped people to answer the questions. Not all surveys have been completed as some people did not understand some questions. We have also received surveys from social and health care professionals. The findings of all surveys have been included in this report. We gathered additional information for this report by looking at a number of records such as peoples care plans, risk assessments, accident and incident records, complaints records, medication administration, staffing records, and health and safety procedures. We were given some copies of policies and procedures that had been updated since the last inspection. Care Homes for Adults (18-65 years) Page 7 of 37 What the care home does well: What has improved since the last inspection? What they could do better: The following requirements have not been met: The Registered Person must ensure we are notified of each significant event which happens in the home to show an accountable and safe service is provided for people. Every allegation of abuse must be reported to the local authority immediately. Staff have been trained in this area and there is a policy and procedure in place for staff to follow. The Registered Person must ensure this is followed so that people living at the home are kept safe. There are still some areas of practice that are unprofessional with the home not always being run in peoples best interests. The staff team are not being managed effectively. Policies relating to poor staff practice or performance are not being practiced. The homes policies and procedures are not being followed by the staff team or the Directors. Care Homes for Adults (18-65 years) Page 8 of 37 Further requirements made as a result of this inspection: The Registered Person must show how decision making processes take into account peoples best interests with issues of consent reviewed. The Registered Person must ensure those people who are responsible for taking their own medication are supported to keep this safely. The Registered Person must ensure the record keeping of peoples finances and the safeguarding of their monies is robust. An external audit of peoples finacial records will help to review and improve current practice. The Registered Person must keep up to date records of peoples property and articles of value. The keeping of detailed individual supervision records will help to monitor more effectively staffs role, responsibilities and performance issues. Peoples bullying risk assessments must include that incidents of this nature are reported to local safeguarding authorities. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 37 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 37 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are given information they need to help make an informed choice about where they want to live. They are assessed before moving to the home so they know their care needs will be met. People living at the home are given written statements of their terms and conditions. Evidence: At the last inspection we understood that the Statement of Purpose was being updated, however this had not been completed to reflect current information. There was a Service User Guide called My Home, that had been developed in an accessible format with pictures, symbols and photographs. We were told that this had been given to people living in the home for information. We were told people living in the home had also been given copies of the Residents Charter. This included statements about their rights and what they should expect from the service. Care Homes for Adults (18-65 years) Page 11 of 37 Evidence: There had been no new admissions to the home since the last inspection and there were no current vacancies. All eight people are funded by the local authority and were previously assessed before living at the home to ensure their needs could be met. Since the last inspection, seven peoples needs had been reassessed by a local authority. Assessments showed peoples needs were being met and that they were happy living at the home. Three people spoken with also confirmed they liked living at the Avenue and felt they were well supported by staff. We reviewed the license agreements and found them to contain information for those who live at The Avenue about the terms and conditions of the placement and notice periods. We found when we first looked at the main care files that these documents were dated 2006 and quoted fees for this period. The manager assured us that all of the people who live at The Avenue had been given copies of up to date license agreement and that they were in individuals rooms. On the second day of our visit we found that the license agreements had been copied and had replaced the out of date agreements within the main care files. Care Homes for Adults (18-65 years) Page 12 of 37 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples care planning provides clear and individual information about the care and support they need. Although people are supported in making choices about their lifestyles, written records do not show how decisions and consent are reached and that they are in their best interests. People are supported safely in taking risks to help enable them to live as independently as possible. Evidence: We read in detail four peoples care plans and sampled files of others living at the home as part of the case tracking process. This means that we spent time reading the records of the people that we selected, and by meeting people, and talking with the staff caring for them, could assess whether the care plans gave the complete picture of how to meet a persons needs. In all instances we found this to be the case in Care Homes for Adults (18-65 years) Page 13 of 37 Evidence: respect of how people were supported to live their life in areas such as their personal care, social lives and to maintain independence skills. We also spoke with a healthcare professional who was visiting to support an individual and they confirmed staff took professional advice and supported people with agreed and appropriate practice. A person centred and essential lifestyle approach to the persons life is used to try and gather as much information about people as possible. Information from these was included in the care plans we read. The quality of information in person centered plans and essential lifestyle documentation was of a standard expected and it was evident that this information had been gathered over a period of time, and through one to one time between people who live at the home and their carers. Care planning documents seen by us were detailed and explicit and the daily diary reports contained entries of what, when and how care was provided. This meets a recommendation from the last inspection for the ongoing record of peoples activities to be noted individually, and in a person centred way. Information recorded on care documentation corresponded with information given from people who live at the home and staff about the level and individualised levels of support people received. It was clear that support provided was flexible and tailored to individuals identified and requested support needs. People living at the home have Residents meetings facilitated by both staff and an advocacy agency when people can talk about different things. We saw written records of Residents meetings where staff had been present. The Improvement Plan we received told us a monthly meeting would also be held with a member of the Management Committee and without staff present. We saw minutes of a meeting on 11th October 2009 but a member of staff had been present to record what was being said. Meetings had also been held with an external Advocacy service. These meetings did not have any staff present and written records confirmed this. The Improvement Plan we received told us the organisation was going to reinforce that the Avenue is their Home and not the staff members, and to ensure their understanding of their Residents Charter. The manager told us the Advocacy service had worked with people living at the home to meet this and records of meetings confirmed people had been supported in understanding some of the areas of the charter and their rights. We saw a record of meetings people had also attended outside of the home called Advocacy network meetings. These were also attended by Care Homes for Adults (18-65 years) Page 14 of 37 Evidence: other people living in the local community and used as a forum to discuss relevant issues. To the question asked in the surveys Do you make decisions about what you do each day we noted that three people said Always, one person said Usually, another said Sometimes and three people answered Never. Within individuals files we noted that consent forms were in place, these covered areas such as medication, money saving and healthy eating. We noted that these consent forms had not been reviewed since April 2008. They provided very little detail about how decisions and consent were reached. Therefore a requirement is made for consent forms relating to medication, money saving (including saving for holidays), and healthy eating to be reviewed. This will ensure the preferences and needs of people living at the home are met and that their money is safeguarded. A requirement is also made for peoples care plans to reflect their best interests and their assessed mental capacity needs. This should demonstrate that people have been properly involved in making decisions about their care and, where staff have acted on their behalf, why and how decisions have been reached. We saw manual handling assessments that outlined information about the support needed by people. These records gave an indication of the level of risk in this area for individuals, the assessments also contained information of staff action/support and equipment needed in order that people are moved safely. Care Homes for Adults (18-65 years) Page 15 of 37 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home have opportunities to take part in various work, projects, leisure and social activities. They are supported to keep in touch with families and friends. People living at the home are involved in the daily routines. They are offered individual, varied and healthy diets. Evidence: People living at the home attend college and day service placements, and there are two people who are in paid employment. People spoken to confirmed activities they were involved with and we saw them going out to both their usual work placements and day services. We saw good reference in the care plans, and timetables, of people living at the home about their hobbies and interests so that staff would know their preferences for activities and what they may not like. These included religious beliefs. Care Homes for Adults (18-65 years) Page 16 of 37 Evidence: Staff have worked closely with the people living in the home to develop detailed essential lifestyle information that gives them the opportunity to live the way they choose. This contains written text, photographs and pictures and records what is important to the person. We saw that each person living at the home had an individual activity programme. This showed that from September to November people are participating in a variety of social and leisure events such as Halloween and Guy Fawkes parties and local music festivals. We saw that people attend drama workshops, bowling, cinema, horse riding as well as visiting the pub, shopping for clothes and going out for meals. Some of the people who live at the home had recently been involved in a photo stories workshop, which produced educational literature about health and safety, fire safety and food hygiene. This had been produced in text and photographic format. A member of staff told us that the people involved in this project enjoyed this piece of work and gained a great deal with the document produced. Daily diary entries read evidenced that staff support people who live at the home to maintain contact with friends and family and the local community. People attend church and local social clubs such as the Gateway Club and a club for people over 18. We saw records that showed people had been supported to visit places of local interest and had gone on boat trips and visited seaside resorts by train and appeared to have had a good time. Since the last inspection all the people living at the Avenue had been on a holiday to Cornwall. People said they had enjoyed the holiday but that the mini bus they were traveling in had been involved in an accident on the way there. This was confirmed by the manager and staff. It was evident the accident had been caused by another vehicle and the police had been involved but that people had not been hurt. However, this incident was not reported to the Commission as required (see Conduct and Management of the Home). Staff told us that visitors are welcome at any time and this was evident from entries in the visitors book. People living at the home also have the opportunity to stay with relatives on a regular basis. People are involved in daily routines. This was seen by rotas showing the different household tasks people help with. People also confirmed this and that they have an individual time to help prepare the evening meal with staff. Written menus were seen Care Homes for Adults (18-65 years) Page 17 of 37 Evidence: to be providing people with both a wide range of healthy and balanced diets. The manager and staff told us that sometimes people had been taken to eat in restaurants and take away meals had been bought. This was seen in the record of meals provided when fish and chips had been bought one evening. People are encouraged to eat healthily and written consent forms agreeing to be supported with a healthy eating diet were seen signed by individuals. A recent record of staff meeting minutes showed staff had agreed that people needed to resume on their healthy eating plans as peoples weight had increased. As previously recorded in Standard 7 consent forms must be reviewed and updated. Two people spoken with confirmed they do their own food shopping and cook their own meals independently. They told us about the sort of meals they cooked and that they always had plenty of fruit. They also said they join the others on Sundays for a roast meal. People living at the home support a business run by people with learning disabilities. They pay the business to provide them with ingredients to make a meal at the Avenue. Pictorial and easy read recipe cards are provided for people to follow. From the information provided through surveys, all but two people answered Yes to the question Can you do what you want to do during the day. All but one person answered Yes to questions about being able to do what you want to do in the evening and at weekends. Care Homes for Adults (18-65 years) Page 18 of 37 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home benefit from their personal support and healthcare needs being met in the way they want. People are supported in taking medication in a safe way. A risk assessment will help decide if an individuals medication is being kept safely. Evidence: Care files showed clear guidance for staff in supporting people with their personal support needs, with individual preferences and routines recorded. All but one survey received from people answered Always to the question Do staff treat you well?. People living in the home are registered with a local doctors practice. Records showed that people are supported with their primary healthcare needs such as the dentist, chiropody and optician. These had all been recorded in individual health action plans and daily diaries. We saw staff contact the individuals GPs or any other health service as required promptly. At the time of our visit there were people who were home as they were unwell following recent vaccinations for the influenza virus, and the manager had contacted individuals GPs for advice in order that individuals were Care Homes for Adults (18-65 years) Page 19 of 37 Evidence: comfortable. Within records we saw that specialist services are also arranged as and when required and we saw that this has included orthotic support, hydrotherapy, physiotherapy and support to attend hospital appointments. There was comprehensive information recorded about meeting the whole range of peoples physical and healthcare needs including details such as recording when the person last has a sight test and the date when they would need an annual check up. Medicines are supplied by a local Pharmacy using a weekly blister pack system. All the medicines used in the home are given by staff. We checked the medication systems used to make sure that they meet the required standards. Support and training is provided by the Pharmacy. Good practice guidelines are followed such as having a photograph of the person needing the medication on their chart. The pharmacy provides printed medicine administration record sheets for staff to complete when they give medicines. These were kept with each persons medicines, along with a copy of the organisations medicine policy. This means that staff can be clear about how to give medicines safely. Medicines were given from the labeled packs provided by the pharmacy. Staff signed the administration record as they gave the medicines. We checked a sample of medicines and these indicated that they had been given as prescribed by the doctor. The records of administration had been completed fully. There is an individual at the home who manages their medication themselves with minimal support from staff, this was working well and the individual was able to maintain some independence and control over this area of their life. When we discussed this situation with a staff member we were informed that the person did not have a facility within their room to lock their medication away. We were informed that the individual had a lockable wardrobe and also locks their bedroom door when they are not in. A risk assessment must be carried out to determine if their medication is being kept safe or whether a specific lockable facility should be provided for them. Care Homes for Adults (18-65 years) Page 20 of 37 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are confident to complain but some complaints have not been acted on in robust way. People are not being safeguarded from abuse as staff have not reported allegations of abuse or kept good records of financial transactions. Evidence: We saw a formal Complaints Policy and Procedure. This sets out how people living at the home and staff can make a complaint, including the recording and monitoring of all complaints. People had also been given a Guide to the Complaints Procedure that is in a pictorial format. We also saw a Safeguarding Vulnerable Adults from Abuse Guidance Policy and Procedure. Since the last inspection, this has been updated with contact names and telephone numbers if abuse is suspected so that staff know who should be informed. A requirement was previously made for the Registered Person to ensure people living at the home are confident to report their concerns and complaints, so that they are safe and their views are taken seriously. We spoke to three people who told us they felt happy to make a complaint and that staff would help them. All but three surveys received from people told us they knew how to make a complaint. On one survey it stated that the person did not understand the question. Care Homes for Adults (18-65 years) Page 21 of 37 Evidence: To the question Do carers listen and act on what you say? three people answered Always, one person said Usually, three people said Sometimes. One person said Never and made the comment could listen to me better. The Improvement Plan we received from the Registered Manager told us people were to be offered support and training in understanding how to make a complaint. We saw records of residents meetings facilitated by an Advocacy service to show this had taken place. We saw a comment written by someone living at the home saying that enjoyed the training. We saw the complaints log that records all complaints made. There had been two recorded complaints since the last inspection. We looked at the detail of the complaints and found that one was about issues between people living at the home, and the other was about an individual who did not want to go to work because a man called xxxxxx was bullying him and stealing his money. A comment had been recorded by staff to say the incident would be looked into. This complaint contained allegations of abuse and we asked the manager, and member of staff involved in supporting the individual to make the complaint, if it had been reported under the Safeguarding Adults Procedures. We were told it had not but that the member of staff had discussed it with a work placement officer who was involved in the individuals work placement, and the work placement manager, and that a decision was made for them not to return to work. This had all been recorded and when we spoke to the individual they said they were happy with the outcome. However it is evident staff did not follow either the organisations or the local authoritys safeguarding procedures. The service is monitored on a monthly basis by the Directors, but there was no comment on the monthly notifications (known as Regulation 26 visits) for this period identifying that the allegation should be referred in line with the organisations safeguarding policy and procedure. Since the last inspection all, but one member of staff, had attended Safeguarding training facilitated by the local authority for the second time. All of the Directors also attended this training. We saw a record of weekly internal staff training where staff had looked at policies and procedures including safeguarding. We saw a record of a staff meeting held on 11 October 2009 where the manager had reminded staff that ALL concerns must be reported to the management, B&NES (Bath and North East Somerset local authority) and CQC (Care Quality Commission) as per policy. We spoke to staff who told us they would report any allegation to the manager, the work placement officer or the directors. We asked staff what had been learnt from the previous safeguarding investigation and the last inspection. We were told have recognised mistakes and more awareness now. Care Homes for Adults (18-65 years) Page 22 of 37 Evidence: The last Key Inspection found staff had not followed policies and procedures and we made requirements for every allegation of abuse to be reported to the local authority immediately so that people living at the home are kept safe. We also made a requirement for the understanding of every aspect of how to safeguard vulnerable people to be clarified with every person who works in the home or in the running of the home. It is evident that although staff had received both internal and external training again, these requirements had not been met. Staff were still not following the organisations policies and procedures, and were making decisions about action to take with people who are not key in local safeguarding protocols. As part of this inspection visit we reviewed the cash held in the home for safekeeping and reviewed the records for 4 people in this area. We were concerned to note that the recording, auditing and accountability within this area were not robust and do not protect people. Records were not clear nor did they cross reference with other monetary transactions made on behalf of people, for example when money had been taken/entered into bank accounts and petty cash. We saw that for every persons records we reviewed there were regular occurrences where receipts for services and products were not obtained, these included chiropody, swimming, hairdresser and bowling. There were also no receipts for clothing alterations or for holidays taken. When receipts were in place we found they were often bunched together with other peoples purchases and no separate receipts had been obtained, thus making auditing difficult and confusing. When examining receipts of purchases we saw that there were items that people had bought were not recorded on an inventory. Items purchased included bedroom furniture, a computer and an Ipod. The manager must ensure that all people who live at the home have an inventory of their property and of things which are of value to them. Furthermore, for those people who have inventories dating back to 2004 these should be reviewed and updated to reflect the valuable property that people have. This will also show that this area has been audited and will reduce the possibility of incorrect and out of date information being held. It was extremely difficult to understand how individuals monies tallied with records held as many receipts did not tally with actual money spent, two examples of this were one individual apparently spent £40 on a gift voucher yet only £20 had been deducted from their funds. On another occasion a person spent £8, as confirmed by the receipt, yet only £4 had been taken from their account. We were also told that people hold cash tins in their rooms where they keep some of their personal allowance. We did not look in these tins to see if the balances tallied up with the cash Care Homes for Adults (18-65 years) Page 23 of 37 Evidence: sheets. It was noted that not all monies were held securely. We were concerned to note that staff had used their own store cards to collect bonus points when purchases had been made for people living at the home. The manager said staff often bought clothing for people if they saw something they may like for them and that it was not for the points on their card. This practice could be perceived as not promoting peoples welfare, or taking peoples best interests into consideration, and is unacceptable and must stop. We have never been alerted to concerns by the directors during their monthly visits to the home or seen any discrepancy they may have found through the Regulation 26 reports regarding peoples financial records. The manager said peoples cash sheets are checked during these visits, but not the receipts. We were told by the manager the organisation has their financial records audited externally. However there are no robust measures in place to monitor how peoples finances are being managed. Care Homes for Adults (18-65 years) Page 24 of 37 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service provides a homely, comfortable and suitably adapted environment for people to live in. Evidence: 6 The Avenue is a large four storey, semi detached house situated in Keynsham. There are six bedrooms over the first and second floor, and a large basement provides a self contained area for two people to maintain a degree of independence. There are kitchen and laundry facilities within this area for people to use. The home is near to public transport such as bus stops and the train station in order that people can access both the cities of Bath and Bristol and further a field if desired. The home is within walking distance to the local amenities such as the Church, banks, post office, shops, cafes and Keynsham park. There is a pleasant large rear garden with seating provided. This area had been well tended. There is parking at the front of the house. There are communal areas for people and they were observed sitting in the lounge, the dining area and going into their rooms, looking very relaxed and comfortable in their environment. The house has a homely feel with photographs, plants, flowers Care Homes for Adults (18-65 years) Page 25 of 37 Evidence: and soft furnishings. The dining room and lounge were pleasant areas for people to enjoy. When we visited the home was tastefully decorated and furnishings were of a good quality. There is no provision at the home for respite placements. There are good arrangements in place for wheelchair access. A passenger lift is in place externally to access the main entrance if unable to use the steps. A stair lift is installed to the first floor for those who need support in this area. We saw in records that this piece of equipment had been recently serviced and was deemed fit for use. There are also adaptations throughout the home with specialist equipment including mobility aids, bathing aids and handrails. At this visit we viewed some bedrooms all were well furnished and had been personalised with artwork, photographs and soft furnishings to reflect individuals taste and choices. Toilets are situated in readily accessible parts of the home near to communal areas and bedrooms. All areas within the home were found to be clean, tidy and odour free. Care Homes for Adults (18-65 years) Page 26 of 37 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home have been supported by a consistent staff team. Staff are trained in areas of meeting peoples general needs. People are not being supported safely by an effective staff team with knowledge put into practice. The home carries out thorough checks on new staff to ensure they are suitable to work in the home. Although staff are supervised on a regular basis, written records do not show how their role, responsibilities and work performance is being monitored effectively. Evidence: At the time of the inspection the staff team consisted of four staff plus the manager. All the staff team had been covering all shifts since January 2009. The manager and staff had worked hard to provide sufficient staffing cover by working additional hours. Staff said they were happy to work the extra hours so that the people living at the home would have consistency with their care and support needs. Two requirements were made at the last inspection relating to staffing. These were that practices in the staff team that were unacceptable, unprofessional and not in the best interests of the people living at the home had to cease and that people are Care Homes for Adults (18-65 years) Page 27 of 37 Evidence: provided a professional and safe service. The other was that staff had failed to maintain good personal and professional relationships with each other and with the people living at the home and that this had to be addressed. The Improvement Plan told us these requirements were to be met through staff revisiting their job descriptions and roles in the home including policies and procedures. Staff confirmed they had been given training in the organisations policies and procedures including the Residents Charter and that they had been given copies. We saw records of regular staff meetings that showed this had taken place. Two staff spoken with told us things were different now and one said that anything I find not right Id report- being friends does not come into it. We saw that staff were maintaining good personal relationships with each other. People we spoke to said they were happy with the staff team and that they worked well together. Comments included in a survey said They run it well, better and better. I would like more staff. Although we saw staff working in a professional and caring manner towards the people living at the home, they are still not following policies and procedures, or understanding their responsibility to keep people safe. A requirement has not been met in reporting alleged abuse so that people are kept safe. Since the last inspection three new relief workers had been employed. Their staff files contained completed applications, three references had been received for two of the staff while two had been received for the third. The Manager said she was waiting for the third reference. Although there have been no family members employed since August 2009, one relief worker employed in March 2009 who is related to a permanent member of staff, has continued to support the people living at the home when required. The manager said the rotas had been developed so that staff who are related, do not work together. Although we saw this practice was seen to be adhered to during the inspection, it was difficult to see how this could be sustainable given the numbers of staff employed. We were given the draft of a new recruitment policy that stated members of the same family should not be employed. The manager said that this will come into operation when permanent staff are recruited in the future. However since the inspection we have been told this has already come into practice. One of the relief workers had already started working at the home and their staff file contained a written record that showed they had been through the induction process. An Induction, Foundation and Training record showed the areas their induction had covered including fire, accidents, practical day to day matters, client care, and medication. We met another new relief worker during the inspection who said this was the third Care Homes for Adults (18-65 years) Page 28 of 37 Evidence: time they had worked in the home. They confirmed they were not doing any personal care tasks but were shadowing staff to understand the routines of the home and start to get to know the people living there. They told us they had been informed by word of mouth about the Avenue and said they wanted to expand their experience in care. Both had previous experience of working with people with learning disabilities. The manager told us she was waiting for Criminal Records Bureau (CRB) checks to come through for two of the relief workers before they started their induction and began to support the people living at the home. We noted up to date CRBs had been undertaken for the Directors and the manager. Staff training files showed all permanent staff had completed training in Mental Capacity and Deprivation of Liberty Safeguards. Other training staff had completed since the last inspection included epilepsy, mental health awareness, dementia, and depression/ anxiety management. Although staff had been trained in recognising and understanding abuse, and knew how to support people safely, this knowledge has not been put into practice. The Improvement Plan showed us that supervision of staff was a key area in helping to meet all the requirements from the last inspection. Recorded staff supervision notes were seen. This showed all four staff had received monthly formal supervision since the last inspection. However there were no detailed notes of discussion with staff about their role or with the member of staff who dealt with the allegation of abuse referred to earlier. The manager showed us a new supervision format that will include safeguarding issues. We would have expected to see this as an ongoing key area of any staff supervision. It is recommended that the manager keeps detailed records of discussion had during individual formal supervision to show issues are being dealt with and work practice is being monitored. Care Homes for Adults (18-65 years) Page 29 of 37 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not well run. Policies and procedures not being followed. Record keeping that is poor and does not safeguard peoples rights and best interests. Evidence: The manager Mrs Hill has managed the service since 1994. We spoke with Mrs Hill and asked her what she had learnt from the previous safeguarding investigation. She told us she had involved herself more in working with staff to see how they are working and relating to the people living at the home. The Manager gave us a copy of her Development Plan. This outlined her developmental action including attending specific training courses such as people management courses. Mrs Hill told us she was booked on a local authority two day corporate training course in February 2010. The manager had received formal supervision from the directors since the last inspection. Supervision notes did not contain detailed information as would have been expected about Principle areas of Concern as set out in the Directors Improvement Plan. We would have expected to see how the managers role and responsibilities were being monitored as the manager is not complying with all of her responsibilities to Care Homes for Adults (18-65 years) Page 30 of 37 Evidence: ensure the organisations policies and procedures are followed, and the Care Standards Act and Regulations are being met. Previously a requirement was made for policies relating to poor practice or performance to be followed. Clearly this has not been addressed. We were told by staff that they had been given a verbal and written warning for failure to follow correct working practice in relation to safeguarding reporting procedures. Although we saw in each member of staffs file a written warning that stated failure to report will result in appropriate disciplinary action, there was a footnote to this written warning thanking staff for their work. Staff also confirmed that at the verbal warning they were given they were also thanked for their work. This does not demonstrate a robust approach to a serious breach of work practice by staff. We saw the Disciplinary Procedure (reviewed 2009) that stated that a verbal and written warning must be coupled with a clear plan for improving the employees conduct or performance. We have been informed since the inspection of a change in the Disciplinary Procedure that does not include a plan for improving employees conduct or performance at this stage. The interests of people living at the home are not safeguarded through robust record keeping. We saw in several instances of peoples records being poorly maintained. Examples of these have been recorded under Standard 7 (consent forms), Standard 23 (financial transactions and peoples inventories). The fire logbook was viewed and was well maintained. The organisation was completing the appropriate checks on the fire equipment and recording of training and testing of equipments were satisfactory. Staff have attended fire drills and completed fire awareness training to ensure that they have clear knowledge of action to be taken in the event of fire emergency. Staff training records showed staff were up to date in manual handling, food hygiene, health and safety (including risk assessment and infection control). There is a detailed fire risk assessment which identifies areas of potential hazard and what action has been taken to minimise this. This document had been reviewed by the manager in October 2009 and no areas of imminent concern were recorded. There was evidence that a safe environment is maintained. Portable electrical appliances were checked for safety in June 2009, a check of gas safety within the home was completed by an appropriate contractor in April 2009. Public Liability insurance was as required. There is a bullying risk assessment within each persons file that outlines to staff their Care Homes for Adults (18-65 years) Page 31 of 37 Evidence: role and responsibility in this area, however, staffs lack of understanding in response to an allegation reported to them by an individual who lives at the home who claimed to have been bullied was not followed. The assessment states what further action should be taken should an allegation of bullying be disclosed to them and directs staff to report incidents to Health and Safety and Care Quality Commission (CQC), and this assessment should be reviewed and updated. It is recommended the assessment includes that incidents must be also reported to the local safeguarding authorities for their advice. A requirement for the Registered Manager to notify us of each significant event which happens in the home had not been met. We were not informed about the allegation an individual made through a complaint (this has been previously recorded under Complaints and Protection Standard 22 and 23). We were also not informed about the mini bus accident people were involved in during their holiday (as recorded under Lifestyle Standard 14). The manager told us that as the accident did not happen in the home she thought there was no need to report it. We advised the manager that people had been in her care and that the notifiable reports (known as regulation 37s) that are sent to us state clearly the action to be taken. Improvement plans received told us Regulation 37s would be monitored through the monthly inspections undertaken by the Directors. We saw these reports of these monthly inspections and saw they had been checked but did not see any action taken by the Directors in following them up. There is no evidence to show these issues were raised with the manager through supervision nor appropriate action to take discussed. Care Homes for Adults (18-65 years) Page 32 of 37 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 23 13 The understanding of every aspect of how to safeguard vulnerable people must be clarified with every person who works in the home or is involved with running it. Although we know staff are now reporting concerns they may have about the people living in the home to the local authority, we have left this requirement partially met as we did not speak to all the staff about their understanding. This will be followed up at the next Key Inspection. The Registered Person must ensure this is carried out to ensure residents are safe. 01/06/2009 2 37 10 The home is not well run and 01/07/2009 is not run in the best interests of the residents. This was not fully assessed and will be followed up at the next Key Inspection. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. 3 40 12 The homes own policies and 01/06/2009 Page 33 of 37 Care Homes for Adults (18-65 years) Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action procedures are not followed by staff members, the Registered Manager or the Directors. This places residents at risk. This was not fully assessed at this visit and has been left as partially met. This will be followed up at the next Key Inspection. The Registered Person must ensure these are adhered to as if they are not, residents are at risk. Care Homes for Adults (18-65 years) Page 34 of 37 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 15 Individual care plans must be developed with each person living at the home that reflects the persons best interests and their assessed mental capacity needs. This will make sure that all the people living at the home have their best interests and mental capacity needs met. 31/12/2009 2 7 12 Peoples consent forms relating to medication, money saving, including saving for holidays, and healthy eating must be reviewed on a regular basis in consultation with them. This will ensure their needs and preferences are met and their money is safeguarded. 31/12/2009 Care Homes for Adults (18-65 years) Page 35 of 37 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 20 13 When medication is being stored in a persons bedroom there must be systems in place to store this securely. This will ensure the people living at the home are protected from risk of harm. 31/12/2009 4 23 17 A robust system must be in place to record people living at the homes expenditure, personal finances, valuables and property. This will ensure people living at the home have their finances and personal belongings safeguarded. 30/12/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 23 36 Carry out an external audit of peoples financial records. Keep detailed records of individual staff supervision so the staffs work performance is monitored and issues are followed up effectively. Include in the peoples bullying risk assessments that incidents of this nature are reported to local safeguarding authorities. 3 42 Care Homes for Adults (18-65 years) Page 36 of 37 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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