Inspection on 28/04/09 for The Avenue

This inspection was carried out on 28th April 2009.

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

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

Other inspections for this house

The Avenue 25/02/10

The Avenue 26/10/09

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 17/02/2010.

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: David Smith     Date: 0 1 0 5 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 40 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 40 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 provide accommodation for eight people 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 selfcontained living area. This comprises of two bedrooms for two residents, a bathroom and a small kitchen. The first and second floor of the property provide accommodation for six residents. A new wet room, containing a fully accessible toilet and shower, has been installed to meet the changing needs of the residents. There is also a new staff Care Homes for Adults (18-65 years) Page 4 of 40 Over 65 0 8 Brief description of the care home sleeping-in room and a new office. A basement has been provided for storage space for old records and 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. There is also a mini bus for residents to use. Care Homes for Adults (18-65 years) Page 5 of 40 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: The last Key Inspection of this service was completed on 20/06/07. This was an unannounced inspection to enable us to complete a Key Inspection of this service. We visited the home over three separate days, spending approximately 14 hours in the home. We had not planned to inspect this service until 2010; however this has been brought forward following the outcomes of a recent safeguarding investigation by the local authority. The inspection was carried out by two inspectors. However, the term we is used in this report because the report, and the judgements within it, are on behalf of the Care Quality Commission. The pre-inspection planning involved reviewing the report of the last Key Inspection completed in June 2007 and the Annual Service Review carried out in June 2008. We Care Homes for Adults (18-65 years) Page 6 of 40 reviewed the local authoritys Report of findings from Safeguarding Investigations completed 28/03/09 and a written statement from one of the Directors which was sent to the local authority. We also looked at the service history, which details all other contact we have had with, or about, the home. We looked at the homes Annual Quality Assurance Assessment (known as an AQAA). This is a self-assessment, which focuses on how well outcomes are being met for the people who live at The Avenue. We also looked at the Relatives, Friends and Agencies Questionnaire Findings completed in March 2009. We spoke with the Registered Manager, two Directors, each member of staff who currently works in the home and, prior to the inspection, two staff employed by the home but not currently working. We met with all of the people who live at The Avenue who were happy to speak with us as a group, without staff support. We viewed all communal areas of the home and some of the bedrooms used by the people who live here. We gathered additional information for this report by looking at a number of records within the home such as individuals care plans, risk assessments, daily records, accident and incident reports, complaints records, medication administration, staffing records and some health and safety procedures. We also asked for copies of a number of policies developed by the home. Care Homes for Adults (18-65 years) Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: Residents living at the home have not been confident to report their concerns and complaints until very recently. This indicates that people have been reluctant to complain as they will not be taken seriously or they may be victimised. The Registered Person must ensure this is addressed to ensure residents are safe and their views are taken seriously. The Registered Person must ensure we are notified of each significant event which happens in the home. This should include all relevant information, including anything recent, which may be connected to each event. This would ensure an accountable and safe service is provided to each resident. 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. The Registered Person must ensure this is carried out to ensure residents are safe. Every allegation of abuse must be reported to the local authority immediately. Staff have been trained to ensure this happens and the homes policy is clear. The Registered Person must ensure every allegation of abuse is reported to ensure residents are safe. Practices within the staff team, which are clearly unacceptable, unprofessional and not in residents best interests are part of the homes culture. The Registered Person must ensure these practices cease to ensure residents are provided with a professional and safe service. Staff have failed to maintain good personal and professional relationships with each other and with the people living at the home and this must be addressed. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. Residents are at risk as staff do not report poor or unprofessional practice and alleged Care Homes for Adults (18-65 years) Page 8 of 40 abuse. The Registered Person must ensure staff report all such issues to ensure residents are safe. There is a comprehensive lack of honesty and professionalism within the staff team; this is further compromised by the friendships or personal relationships within this team. The Registered Person must ensure this is improved as this compromises residents safety. The home is not well run and is not run in the best interests of the residents. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. The staff team is not managed effectively. Policies relating to poor staff practice or performance are not being followed. This allows poor or inconsistent levels of support for residents to continue. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. The homes own policies and procedures are not followed by staff members, the Registered Manager or the Directors. The Registered Person must ensure these are adhered to as if they are not, residents are at risk. The ongoing daily records of residents activities are not person centred and do not always reflect the true picture of events that have or have not occurred. The Registered Person must ensure these are improved as this practice does not safeguard the best interests of residents. 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 40 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 40 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. Individuals are given the information they need about the home to enable them to make an informed choice about where to live. People are confident the home can support them as their needs are thoroughly assessed before they are given the opportunity to move in. Each resident is provided with a written statement of terms and conditions. Evidence: There is a comprehensive Statement of Purpose, that is currently being updated. In addition to this there is an Operational Policy and a Resident Charter of Rights. These provide clear information regarding the services offered at The Avenue. The Service User Guide is in an accessible format, both symbolised and pictorial also helping residents to understand what is on offer. There have been no new admissions to the home for a number of years and there are Care Homes for Adults (18-65 years) Page 11 of 40 Evidence: no vacancies. However, if a vacancy were to arise, the home has a thorough assessment process which would show whether the home would be suitable for any person interested in living here. All eight residents are funded by the local authority and have been admitted to the home through the care management process. Four peoples care files seen confirmed this. People have been given a Licence Agreement between themselves, the home and the Landlord, Places for People Housing Association. This helps tell residents about the terms and conditions of their stay. All eight residents are a long established group having lived together for many years. All residents were spoken with during a group meeting. They said I like living here now and Im happy. We received a written letter from one person also confirming they liked living at the home. Care Homes for Adults (18-65 years) Page 12 of 40 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individuals needs and goals are met and each person has a plan that they, and people close to them, have been involved in making. Each person is supported to make decisions about their lives and to take risks to enable them to live as independently as possible. Evidence: Four care plans were looked at in detail and they provide comprehensive information on the areas of support each person requires. Each plan is written in an individual way and covers key areas of support. These include information relating to health, personal and social care, independence training (including personal and living skills programmes) and money management. The care plans also describe more complex needs, such as how to respond and support an individual if they become distressed. Care Homes for Adults (18-65 years) Page 13 of 40 Evidence: It is evident residents are involved in their care planning. Care files seen show people have also chosen to have a person centred plan. These were facilitated by an external source so that they are independent from the staff team. Residents are supported by a keyworker, who is a named member of staff who plays a key role in co-ordinating the services they receive. They meet with their keyworker on a monthly basis to review all aspects of their care plan; those care plans examined have been reviewed on a regular basis by the home. Currently four staff working and the Manager are sharing keyworking roles. Formal review meetings are clearly recorded and the outcomes used to update individual care plans. These include residents, family members, social workers and staff. Three residents have had their care reviewed formally by the local authority in 2008; the remaining five residents have not been reviewed formally for four years. We spoke with all the residents at a group meeting to find out their views about how they made decisions and choices about their lives. Although four people were more able to talk about their experiences, the others were agreeing to what was being said. They told us they had meetings to talk about things they wish to do, choosing food, attending various activities and the routines of the home. These meetings are supported by external advocates and written records were seen showing easy read summaries which used plain English and contained picture symbols. Some residents choose to take part in local advocacy network meetings that are also facilitated by external advocates. These are held every two months and discussions are centred on what people need. One resident is also going to advocacy training. Residents told us that they are happy with the four staff members currently working at the home and that they helped them to make choices. They also said that some staff members havent always listened to them in the past or acted on what they said. This is recorded fully in both Standard 16 and Standard 22. Care Homes for Adults (18-65 years) Page 14 of 40 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person is treated as a individual and has opportunities and appropriate support to access leisure and educational facilities. Individuals are able to keep in touch with families and friends. Peoples rights are not being respected. People have healthy, well presented meals which they are involved in choosing. Evidence: Residents have access to meaningful opportunities to help promote their own individual lifestyles. Care files and timetables of activities show the different opportunities individuals are offered, such as regular access to day services, college courses, work placements, shopping, cinema, pubs, swimming, and horse riding. Two residents told us about their paid work and how much they enjoy it. Another told us about the band they play with. The home has a mini bus and staff support Care Homes for Adults (18-65 years) Page 15 of 40 Evidence: residents to get to their different activities. One person holds their own individual budget and the home helps them to organise activities of their choice during the week. They have employed a support worker for two days a week to help them access the activities they want. These include keep fit, cooking, and arts and craft. Detailed records are kept of these and signed by the support worker employed by them. Although staff are recording significant events and other personal information, there is only a general record kept in a diary of other residents activities and how they are supported by staff. Housekeeping tasks are also included and the manager was advised to keep these separate so that they can be monitored more effectively. The manager told us she became aware that a resident did not attend a planned activity after she asked the resident how it went. The resident told her staff too busy. This was confirmed by the resident. Complaints have also been raised recently by residents stating a New Years Eve party that had been planned, never happened. This was also confirmed by residents spoken with. One person said they liked to bang the saucepan lids to see the New Year in but they didnt do it and that people just went to bed early. This shows ongoing daily records of residents activities are not person centred and do not always reflect the true picture of events that have or have not occurred. This practice does not safeguard the best interests of residents. 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. Individuals rights and responsibilities are made clear and confirmed in writing in their guide to the service and the residents charter. However it is evident that some staff have not followed this practice. Residents wanted to talk with us at a meeting about the way some staff had treated them. We were told by a resident that staff have laid on the chairs in the lounge while they watched television and that a staff members young children had come in on weekends, while they were on duty, and knocked on their bedroom doors. One resident said he had been told to go to bed earlier than he wanted to and that his coat had been hidden as staff didnt want him to wear it. Another resident told us about the most recent holiday they had been on, when one staff member had shouted at another and that this had been upsetting. This practice by staff does not respect peoples rights, as set out in the residents charter and is disrespectful to the people living in the home. The residents are involved in the daily routines of the home. Household rotas in the kitchen identified tasks that are shared. Everyone accesses the kitchen and has a turn in preparing an evening meal with support from staff, and prepare their own drinks Care Homes for Adults (18-65 years) Page 16 of 40 Evidence: and snacks. Weekly menus are planned in consultation with residents and these show a wide range of food, which provide both a healthy and balanced diet. Each persons likes, dislikes and allergies in relation to food are known and clearly recorded. The manager told us alternatives are offered if another type of meal is preferred and we advised for a record to be kept of this. Residents support the Good for You Catering Crew, a group of people who have learning disabilities, who provide the home with ingredients to make both a starter and main course together with pictorial and easy read recipe cards for residents to follow. The Residents are encouraged to send back a comment sheet and suggestions for the next weeks meal. Care Homes for Adults (18-65 years) Page 17 of 40 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 receive personal support in they way they prefer and their health care needs are met. The home supports each person with their medicines in a safe way. Evidence: Care files show clear guidance for staff on how they should support those living at the home with their personal care. Residents preferences and routines were individually recorded showing how they want to be supported. Health care records confirmed that people have access to health care services both within the home and in the local community. People are registered with a General Practitioner (GP) and go to local dentists, opticians and other community services with support from staff. Personal Report Notes are kept of peoples health care showing their needs are being monitored by staff. The home is meeting residents changing health care needs. This was evident with the changes made to the environment. A new ground floor wet room has helped support those people with changes to their mobility. Care Homes for Adults (18-65 years) Page 18 of 40 Evidence: Specialist services are accessed when an identified need arises. The home has good working relationships with the local Community Learning Disability Team. Residents are regularly supported by the Consultant Psychiatrist, Physiotherapists, Speech and Language Therapists, Occupational Therapists and other relevant health care professionals. The home also supports residents to use other services such as reflexology, massage, and aromatherapy. Records are kept of contact with each professional or use of therapies and forms part of each persons care plan. Since the last inspection the home has worked hard supporting people to develop individual Health Action Plans; professionals from the CLDT have supported residents with this process. These contain information that is important to the individual and have been produced using a format that each person can understand. Photographs have been included, such as of residents doctors, helping to make the document more meaningful. Health Action Plans also include how people communicate, how to stay healthy and safe, and actions to support people with positive behaviours. The home uses a monitored dosage system of medication administration, which is well managed. Each person has their own medicine profile as part of their care records; these give staff clear instructions to follow, such as how and when people prefer to take their medicines and also explain what the medicines are for. Staff generally support each person to take their medicines. They always make sure people take them at the right times and only sign the records when they have done so. Each members of staff who supports individuals with medication is trained to do this in a safe and effective way. Medicines are stored securely in the home. Each weeks medicine stock is stored separately as are any medicines used as and when required, such as painkillers or cough mixture. Care Homes for Adults (18-65 years) Page 19 of 40 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. If individuals who live in the home have concerns about their care it is not clear if they are confident enough to complain or if their views are always listened to and acted on. People are not safeguarded from abuse, neglect and self harm and the home does not take the correct action to follow up any allegations. Evidence: The home has a formal Complaints Policy, a Safeguarding of Vulnerable Adults and a Whistle Blowing Policy, which is designed for staff to use in confidence to raise any issue or concern they have regarding the service. Staff have signed to say they are aware of each of these policies and that they understand them however they are clearly not following them. The Avenue usually receive very few complaints and it is very unusual for anyone who lives in the home to complain about their care and support. However, during February and March 2009 residents used the complaints procedure 18 times. We looked at the details of every complaint: 13 relate to an individual resident feeling staff have treated them badly, 2 where a resident felt staff members have treated each other badly and 3 were issues between residents. Complaints by residents about staff members include (two members of staff) shouting at me, being made to go to bed (earlier than they wanted to), (one member of Care Homes for Adults (18-65 years) Page 20 of 40 Evidence: staff) shouted at me. I dont like being shouted at, I was sent to my room, (one member of staff) hid my coat, I dont like (one member of staffs two children) coming downstairs, they scream and shout and (the only two members of staff) sleeping in the front room and doing their own washing. I had to wait. Most complaint reports do not include the exact date of the incident, however, it is clear from speaking with residents and staff that some of these incidents are alleged to have happened several months ago or in previous years. Some residents told us that even though they had only made one complaint, for example being shouted at or staff bringing their children to work, these incidents happened more than once. Staff treating residents in this way and acting in this manner is clearly in breach of the residents charter of rights. Some of these complaints contain allegations of abuse towards people who live in the home; these allegations have been known for some weeks. We asked the Manager if these have been reported under the safeguarding of vulnerable adults procedures and Mrs Hill said they had not. Later she said the allegations have been discussed as part of the recent safeguarding investigation, described in detail below. We have therefore checked this claim with the local authority; they told us there was definitely no mention of these allegations before. We have therefore now referred them under safeguarding as staff at The Avenue should have done immediately when the complaints were made. We have spoken to residents during previous inspection visits; they have never raised any such issues with us. Each resident completed a survey for us in June 2008 to enable us to carry out an Annual Service Review; they said they were happy and knew how to complain if they were not. Whilst it is positive that residents feel they are now able to complain, it is not clear why they didnt when these incidents occurred. When we asked residents why they had not complained earlier they did not answer. The staff we spoke with told us they were aware of some of the issues, such as staff members shouting at residents, bringing their children to work, laying on the sofas watching TV all evening and bringing their own washing into the home. One member of staff said some of these things had not changed since they started working in the home, over 6 years ago. We asked staff why they had not spoken up before or followed the homes policies; the homes Whistle blowing policy says we wish to encourage our staff, at all levels, to keep their eyes open and to raise such concerns in a sound way to demonstrate Care Homes for Adults (18-65 years) Page 21 of 40 Evidence: and ensure good practice in all our activities. We consider that examples of potential malpractice include negligence, abuse of those in care, unethical conduct and the cover up of any of these They said they are afraid of the consequences or fear reprisals. One member of staff said they did report their concerns regarding one colleagues poor work practice in 2005. They felt this was dealt with appropriately by the Manager, however the colleague involved later threatened them and they told us since that time I didnt report anything, I wouldnt dare say anything; keep your mouth shut and do the work. Another member of staff told us they had been bullied by a colleague since working at the home. They have never reported this and this left them feeling as if they couldnt raise issues as they are afraid. In relation to making sure each resident is safe, staff have been trained to identify and report abuse; the home has a clear policy closely linked to the local authoritys policy. However, abuse alleged to have occurred over a number of years was not reported to the local authority until February 2009. The subsequent investigation uncovered the following In October 2008, staff members asked to meet with directors of the home while the Manager was on holiday; it was anticipated pay issues would be discussed. The first meeting, attended by all staff and one Director, did address pay issues but other issues, in particular verbal accusations of the manager abusing residents over a number of years, were discussed. The Directors report said the allegations seemed to have the general support of all the staff at the meeting. At a second meeting four days later, attended by five staff and two Directors, some staff circulated a written list of allegations which included 11 separate incidents of alleged verbal or physical abuse by the manager towards the people who live in the home, some dating back to 2003. Despite allegations of abuse being made at two meetings which staff attended, nothing was reported at the time to the Commission or local authority by any member of staff under the safeguarding of vulnerable adults procedures. They have all had training in this area; some staff have attended this training twice since working at The Avenue. In fact, some staff now said they no longer supported these allegations and staff seem to have argued at this meeting; one member of staff said they kept saying it was abuse, it wasnt abuse. Care Homes for Adults (18-65 years) Page 22 of 40 Evidence: Neither Director reported any of these allegations either. One Director we spoke with (and who produced a report during the local authoritys safeguarding investigation) said they had read the local authoritys policy and felt there is some ambiguity in the BANES (Bath and North East Somerset) procedure about reporting allegations of abuse. We read this policy in the presence of this director and found it to be very clear, as it should be to any person reading it; the homes own policy is closely linked to it. Also, if the Directors were unsure of the policy, felt it ambiguous and did not know what action they must take, they did not clarify this with staff members, the homes Manager or any other body. The Directors report says that they spoke with the Manager, (who was still on holiday), on 28/10/08 to outline the case against her. The report suggests the Manager was advised of the allegations against her at this time, as it states her return was partially dependent on whether the subject of abuse could be satisfactorily resolved. However, the manager told us this was not the case. She said the first she knew of the allegations of abuse were during her meeting on the 5th November with two Directors. Clearly there is some discrepency. We were unable to ascertain the correct sequence of events. The Directors report says we told her the detailed charges...we also asked her about the abuse charges; these were denied and they concluded abuse had not occurred. We asked the Manager if she asked the Directors if these allegations had been reported under safeguarding; she told us she had not and did not consider doing this herself. We also asked if at any time she had been suspended; she told us she had been asked not to return to work after her holiday, until the meeting with the Directors, but she had never been formally suspended, in writing, in accordance with the homes policy. The Directors report says only the fact that Helen was on holiday saved her from suspension. Again it has not been possible to ascertain what actually occurred. The local authoritys safeguarding investigation report concludes some of the allegations which have been reported have occurred, however the perceptions of situations vary between certain staff and the Manager. There is little or no evidence to substantiate allegations of abuse. The investigation raised many issues of concern that have contributed to the situation these include Directors, Managers and Staff not adhering to policies, protocols and processes, lack of professionalism, lack of confidentiality, poor management practice and differing practices between staff. Care Homes for Adults (18-65 years) Page 23 of 40 Evidence: We have spoken with staff at previous inspections; no issues have ever been raised with us although staff now tell us some issues are longstanding. Six staff completed surveys for us as part of the last Annual Service Review; not one of these mentioned any issues detailed above or poor work practice, although staff members now tell us there were issues at this time. Early in 2009 the Manager told us that due to inter staff relations action was taken against some employees. However, we are now aware that allegations of abuse involving the Manager were raised at this time. We were not advised of this by the providers. When we challenged the manager she said I told you what the Directors told me to say. I wasnt happy having to contact you, I felt the Directors should have done this. It is very unlikely that any of the issues to do with the alleged abuse of vulnerable service users would have ever have come to light had there not been a staff dispute in October 2008, which caused more unrest in the staff team. The local authoritys safeguarding report said it is not clear why the allegations were not made at the time of each incident, reported at monthly inspections by the Directors or at CSCI inspections. Also whether they would have been reported if staffing and pay dispute issues had not occurred. Care Homes for Adults (18-65 years) Page 24 of 40 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 Avenue provides a homely, comfortable and suitably adapted environment for people to live in. Evidence: The Avenue is a large, four storey, semi -detached stone-built, property situated in Keynsham. There are car parking spaces to the front and a large garden and patio area to the rear of the property. The home blends in well with the local community and is situated in a very quiet location. Residents can get to the local shops easily, making use of the local amenities. This is of benefit to their personal and lifestyle needs. There are easily accessible public transport routes to Bath, Bristol and other local areas. All areas of the home are clean and tidy and furnishings and fittings are of a good quality. The house is tastefully decorated and there are many photographs of residents displayed, which help to personalise the home. Each part of the home is very light and airy. Two peoples bedrooms were seen. These have been decorated individually and showed that their personal interests and preferences are respected. The manager told Care Homes for Adults (18-65 years) Page 25 of 40 Evidence: us bedrooms have been redecorated since the last inspection. Each person has a key to their bedroom and one resident showed us their bedroom, using their key. They told us they had chosen their colour scheme. The home is fully accessible to all residents. Since the last inspection a ground floor extension has been built to one side of the property. This has provided the home with additional space and facilities. A new wet room, containing a fully accessible toilet and shower, has been installed to meet the changing needs of the residents. 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 other items. The existing utility room has been relocated with suitable flooring that can be cleaned easily. New washing machines and driers are in place and residents are beginning to use this new facility. This will prevent staff and residents having to walk through the basement kitchen. Care Homes for Adults (18-65 years) Page 26 of 40 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. Peoples needs are not consistently met and they are not provided with safe and appropriate support by the staff team. Thorough checks are carried out on new staff to ensure they are suitable to work in the home. Evidence: The Avenue has a small staff team of seven people to support the people who live here. At the time of this inspection, due to employment issues, only four of the seven were working. This had been the case for several months as employment issues remained unresolved. The Manager and remaining staff have worked hard to provide sufficient staffing cover since this time by working additional hours. Each member of staff we spoke with said it is their choice to work extra hours and they are happy to continue doing this in the short term. The roles and responsibilities within the staff team are not clear. All of the staff, apart from the Manager and her Deputy, are Assistant Home Managers; the expectations placed upon these staff are the same. However, the staff firmly believe, and described to us in great detail, how members of this team are their seniors depending on their length of service and qualifications. Care Homes for Adults (18-65 years) Page 27 of 40 Evidence: This belief has led to staff failing to report poor practice or incidents which are potentially abusive. The staff we spoke with are clear that they did not report some staff for upsetting residents, not sharing the workload or laying on the sofa watching TV when they should have been supporting residents because they were my senior. Even though this seniority within this team does not exist, this feeling has persisted for some time. This lack of professionalism has been further compounded by the personal relationships and friendships within this team. Three members of the staff team are family relations; four members of the staff team are close personal friends outside of work. It is clear that the staff have let these relationships and loyalties affect the way they work and have contributed to residents being made unhappy or being placed at risk. Some complaints made recently by residents are about staff shouting at each other whilst at work. One resident said I didnt like it when (one member of staff) made (two other members of staff) cry on holiday. It upset me. Staff told us this was on the residents holiday in 2007. The Manager gave us examples of poor staff practice, such as staff bringing their children into work with them or not allowing residents to have a party planned for New Years Eve, but said she was not aware of these incidents when they happened as staff had not reported them to her. Some of the recent complaints made by residents about staff clearly state that two members of staff were involved, so these incidents were witnessed. Residents are usually supported by at least two staff, it is therefore difficult to see why incidents are not reported if staff are being honest, open and professional. There is a lack of confidentiality within the staff team. Members of the team appear to know extremely personal details about each other and it appears that issues relating to The Avenue have been openly discussed. This evidently caused unrest in the team; one member of staff told us they (some staff) went on holiday and when they came back the staff team was split because of what was said while they were away. Local authority officers carrying out the investigation were also concerned about the lack of confidentiality. Their report says in the letter inviting each member of staff to interview, everyone was asked that the interviews should be kept confidential, this was clearly not adhered to. Members of staff referred to other staffs interviews. The Care Homes for Adults (18-65 years) Page 28 of 40 Evidence: homes grievance and disciplinary policies state that divergence of any confidential information is considered gross misconduct. The residents we spoke with said they like the present staff team and feel they are well supported by them. Again, it is not clear why residents did not raise any issues about how they were treated by staff prior to February this year, despite having numerous opportunities. There are very few staff meetings being held; only two were held in 2007 and again only two in 2008. Staff told us they did not feel confident speaking openly at the ones which have been held, so these had not been effective anyway. The records of the meetings we looked at do not show any of the issues within the team or relating to poor work practice ever being discussed. Staff are provided with a variety of training courses. The records we looked at show that staff have attended many courses including; first aid, how to move and handle people safely, food hygiene, how to safeguard vulnerable adults, competence in care and staff have also attained a National Vocational Qualification. It is clear that staff know how they should support residents, how to ensure they are safe, what they are expected to report and what professional standards are expected of them. There is little evidence that this knowledge is put into practice and there is also very little evidence that these failings are ever addressed with them. This is certainly not in accordance with the homes policy on staff misconduct. Staff have generally been supervised regularly since our last visit, having a 1:1 meeting with the Manager every six to eight weeks. We looked at the supervision records for every member of staff and these confirm that issues within the home have very rarely been discussed by staff, even though these meetings are meant to be confidential. We could only find one or two examples but exactly what was discussed is not clear. One simply said tensions with manager resolved (November 2008) and another said discussion on management and deputy relationship December 2009 (we presume this should read 2008). Staff members were not supervised at all between May 2008 and November 2008. It is clear from speaking with staff there was a split within the staff team, more so since the holiday in April 2008. Why staff supervision then ceased during this very difficult period is not clear. The Manager told us some staff didnt want to have supervision and it just became really busy, so supervision stopped and were only resumed in November 2008, much too late to help try to manage and resolve the division within Care Homes for Adults (18-65 years) Page 29 of 40 Evidence: the staff team. We looked at the recruitment records for staff and these show checks are carried out when new staff are offered positions in the home. They need to complete an application form, attend a formal interview, provide documents proving their identity and eligibility to work in the UK, at least two satisfactory references and an Enhanced Criminal Record Bureau Disclosure, before they start work in the home. Care Homes for Adults (18-65 years) Page 30 of 40 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 and residents do not benefit from how it is managed. The views of the people who live in the home, or those close to them, are sought to help the home review their practice. Residents are not safeguarded as policies and procedures are not followed and staff do not appear to understand the ways things should be done. Evidence: The Registered Manager, Mrs Hill, has managed the home since 1994. We spoke with Mrs Hill at length during our visits to the home. She told us she was unaware of many of the issues within the staff team and some of the poor practice which upsets residents or places them at risk. She did tell us that she felt there were tensions between herself and some members of the staff team as long ago as January 2008, although when she discussed this informally with the staff concerned they said there were no issues. Care Homes for Adults (18-65 years) Page 31 of 40 Evidence: Mrs Hill told us she could not believe staff had not brought these issues to her attention. She said I thought I was approachable, although it is clear that staff do not feel able to do this and it is not clear why. Also, it is not clear how poor and unprofessional staff practice, accepted and condoned by every member of the staff team, has seldom come to the attention of the manager; some of these practices have remained unchanged for a number of years. When issues have been reported to the Manager they have not been dealt with appropriately. One example we discussed involved one member of staff bringing their children to work with them on more than one occasion. When the Manager was told of this, she simply offered to provide child care for this member of staff; there is no evidence that the Manager explained how unprofessional this is or that this member of staff was disciplined in any way. One member of staff is allowed to start work later than their colleagues due to problems with child care. Other staff told us that the Manager also provides child care for them, which enables them to attend training sessions. It is clear that this practice, although done in good faith, has severely compromised the Managers position in the home and their professional boundaries with staff. The residents are involved with the day to day running of the home and also have their own regular meetings if they wish. The home also encourages the use of advocacy to support each persons involvement and to help people express their views and make informed decisions. It is not clear why, despite these measures, that residents have not spoken about staff upsetting them, not listening to them or respecting their choices, before February 2009. This is clearly in breach of their charter of rights supplied to them by the home. The home has a number of policies and procedures, which are designed to ensure residents are safe, that the service complies with the law and remains aware of best practice or new ways of working. Full details of each policy were provided by the Manager on the AQAA she completed as part of this Key Inspection process and we asked for copies of several policies during our visit. Despite this it is clear from speaking with Directors, the Manager and staff members, and looking at other forms of evidence such as the local authoritys safeguarding investigation report and the statement written by one director to the local authority, that a number of these policies are not followed. The homes AQAA is a legal requirement and should provide an accurate self Care Homes for Adults (18-65 years) Page 32 of 40 Evidence: assessment of the quality of the service provided at The Avenue. However, we do not agree with how the home has rated itself in several key areas as the evidence we have collected during our inspection does not support these judgements. We do not agree that service delivery is always in a person centred way, that care given and level of support are dictated by the residents in a manner and pace they feel happy with, that residents views are listened to and acted upon, that residents are protected from abuse, that staff work above and beyond what is expected of them or that residents rights, welfare or best interests are safeguarded. When we spoke to the Manager at the end of this inspection and discussed the outcomes of the inspection, we went through each of the areas which need to be improved noted in the summary of this report. We asked if she disagreed with any of our findings; Mrs Hill said no, because you have the evidence for every one of them. I am just so sorry and sorry for the residents. Directors visit the home each month to carry out audits of the service; one is focused on the environment and another looks at a selection of records kept in the home. Directors also visit the home at other times, such as when they visit relatives who live here. We spoke with two of the Directors as part of this inspection; they supported the inspection process however one director was very unhappy with the timing of our visit and said it was ill conceived although we did explain it was timed in response to concerns being raised about the home and the safety of people who live here. There are recording systems in place to support health and safety in the home. We examined the fire log, which shows that there is a Fire Risk Assessment and that regular fire drills are carried out so the staff and residents know what to do if there were a fire. The homes AQAA confirmed that portable electrical appliance safety checks were carried out in July 2008, the fire detection and alarm system was checked in March 2009 and that the safety of the gas appliances have been checked. They have appropriate insurance cover; the current certificate is displayed in the home. The home has developed a number of general Risk Assessments to promote the welfare and safety of people who live in or work at the home. These are clearly written and subject to regular review. Care Homes for Adults (18-65 years) Page 33 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Adults (18-65 years) Page 34 of 40 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 22 22 Residents living at the home 01/06/2009 have not been confident to report their concerns and complaints until very recently. This indicates that people have been reluctant to complain as they will not be taken seriously or they may be victimised. The Registered Person must ensure this is addressed to ensure residents are safe and their views are taken seriously. 2 23 37 The Registered Person must ensure we are notified of each significant event which happens in the home. This should include all relevant information, including anything recent, which may be connected to each event. This would ensure an accountable and safe service is provided to each resident. 01/07/2009 Care Homes for Adults (18-65 years) Page 35 of 40 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 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. The Registered Person must ensure this is carried out to ensure residents are safe. 01/06/2009 4 23 12 Every allegation of abuse 01/06/2009 must be reported to the local authority immediately. Staff have been trained to ensure this happens and the homes policy is clear. The Registered Person must ensure every allegation of abuse is reported to the local authority immediately to ensure residents are safe. 5 31 21 Practices within the staff 01/07/2009 team, which are clearly unacceptable, unprofessional and not in residents best interests are part of the homes culture. The Registered Person must ensure these practices cease to ensure residents are provided with a professional and safe service. Staff have failed to maintain good personal and professional relationships 01/07/2009 6 31 12 Care Homes for Adults (18-65 years) Page 36 of 40 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 with each other and with the people living at the home and this must be addressed. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. 7 32 21 Residents are at risk as staff 01/06/2009 do not report poor or unprofessional practice and alleged abuse. The Registered Person must ensure staff report all such issues to ensure residents are safe. 8 32 12 There is a comprehensive lack of honesty and professionalism within the staff team; this is further compromised by the friendships or personal relationships within this team. The Registered Person must ensure this is improved as this compromises residents safety. The home is not well run and is not run in the best interests of the residents. The Registered Person must ensure this changes to 01/07/2009 9 37 10 01/07/2009 Care Homes for Adults (18-65 years) Page 37 of 40 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 ensure residents are provided with a professional and safe service. 10 38 10 The staff team is not 01/07/2009 managed effectively. Policies relating to poor staff practice or performance are not being followed. This allows poor or inconsistent levels of support for residents to continue. The Registered Person must ensure this changes to ensure residents are provided with a professional and safe service. 11 40 12 The homes own policies and 01/06/2009 procedures are not followed by staff members, the Registered Manager or the Directors. This places residents at risk. The Registered Person must ensure these are adhered to as if they are not, residents are at risk. 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 41 The ongoing daily records of residents activities are not person centred and do not always reflect the true picture of events that have or have not occurred. This practice does Care Homes for Adults (18-65 years) Page 38 of 40 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 not safeguard the best interests of residents and the Registered person should improve this. Care Homes for Adults (18-65 years) Page 39 of 40 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. Care Homes for Adults (18-65 years) Page 40 of 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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