Care Home: Cowden Road, 52 - 54

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What the care home does well The personal, health and social care needs of prospective residents are thoroughly assessed prior to admission to the home ensuring that the residents can be sure that their needs and aspirations can be met. Residents are their family are invited to visit the home before making a decision to move there and that they receive a contract specifying terms and conditions of residency. The care plans are personalised and individually prepared incorporating the complex needs of the particular resident; making sure that they promote independence and choice whilst respecting their dignity and privacy; enabling them to take acceptable risks and make decisions on how to achieve their aims and personal goals. Residents are supported and encouraged to participate in educational, leisure and local community activities within the local area and at various social and holiday venues; enabling them to lead independent and fulfilling lives within and outside the home environs. The manager and staff of the home have the skills and competency to understand and meet the complex health, personal and social care needs of each resident enabling them to maintain their privacy, dignity and independence The home has systems in place to make sure their residents feel safe and protected at all times. The home provides a clean, hygienic, homely, comfortable and safe place for their residents to live in; enabling them to have rooms and facilities tailored to their individual needs. The manager and staff team are trained and supported to have the skills and competency necessary to meet the personal, health and social care needs of the residents; this is evidenced by the policies and procedures relating to recruitment and selection, appropriate training, and effective supervision and appraisal. The residents and staff benefit from efficient and effective management by a qualified, experienced and competent registered manager, enabling the residents to fell safe and secure and the staff supported and encouraged in their work Overall the assessment has identified the service is meeting peoples individual support needs through identified assessments. Through the introduction of the PCP system the persons living in the service have greater control and say what happens in the lives. Staff training needs are identified and action plans are completed to ensure all parties are aware of their responsibilities. Family members and friends are encouraged and supported to be involved in reviews and changes to care provided to their relative through the review process; and with the introduction of the email into the service, the service users are able to correspond to members of family all over the world. What has improved since the last inspection? What the care home could do better: This was an excellent inspection and it the home continues to provide an excellent quality service to the people who use the service It is evident that the home manager and his staff are committed to promoting the well being of the residents in their care. The home is to be commended on the excellent range of educational, leisure and social activities offered to the residents; the residents spoken to were very appreciative of the efforts of the manager and the staff of the home to help them enjoy life in and outside of the home. The manager and staff of the home are committed to empowering the people who use the service to have a greater say about their lives and encouraging and supporting them in making choices in their home and community. The people who use the service are to be involved in staff recruitment in the future; this will be achieved through training, PCP Reviews and attending recruitment selection with staff members from the service. The home manager has identified the need for clear communication with Avenues Head Offices to ensure all aspects of the service identified will be achieved, by making sure there is a thorough and effective IT system in the service; this would ensure that there is clear communication with external parties enabling the service to broaden the social network to the people they support to live in their home. CARE HOME ADULTS 18-65 Cowden Road, 52 - 54 52 - 54 Cowden Road Orpington Kent BR6 0TR Lead Inspector Sue Meaker Key Unannounced Inspection 18 & 20th November 2008 16:30 th Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cowden Road, 52 - 54 Address 52 - 54 Cowden Road Orpington Kent BR6 0TR 01689 896591 01698 896591 cowden.road@theavenuestrust.co.uk glebe.house@theavenuestrust.co.uk The Avenues Trust Ltd Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Andrew Crees Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 3rd November 2006 Date of last inspection Brief Description of the Service: Cowden Road comprises of two terraced houses converted into one property providing support in a residential setting for five adults, of either sex, with a learning disability. The home is situated in a residential area within a cul de sac, close to Orpington town centre, with a good range of shops, leisure facilities and public transport links. All five residents have their own well appointed bedrooms, one is on the ground floor and has an en-suite bathroom comprising of a walk-in shower and toilet. The other four bedrooms are on the first floor, accessed by steep stairs with banisters either side; all the bedrooms have a vanity unit and also have access to a family sized bathroom on this floor, there is also a separate shower room and toilet for the residents use. The residents have access to an attractive well-maintained garden to the rear of the house; in which staff and residents have planted a variety of vegetables as well as flowers and shrubs; the staff and residents have constructed a pond in which they keep fish. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was a statutory unannounced key inspection comprising of two site visits to the home, one to speak to the peoples who use the service and the staff on duty and a second one to speak to the registered manager and to look at relevant documentation; looking at care plans, medication documentation, staff files, training records, policies and procedures, health and safety documentation and staff files. The complaints log and accident and incident reports were checked; the CSCI had not received any complaints about this home and there had been no adult protection issues. The home manager provided an in depth Annual Quality Assurance Assessment document, information from this document has been used in this report; the registered manager also gave copies staff rota, a weekly menu and the quality assurance records in the form of Regulation 26 visits. All the residents in the home had completed the questionnaires sent to them by the CSCI – all the comments made by the residents in the questionnaires were positive and complimentary. They said that they loved the home and the people who care for them, that they had plenty to do and that they were helped to choose things to do within their capabilities and that they were involved in how they wanted to be cared for and that they liked the talks they had with the manager and staff about holidays and days out; they were also looking forward to going out for Christmas lunch with the manager and staff, they said they had chosen where they wanted to go; they were also looking forward to all the things that they would do over Christmas and the new year, going to the pantomime ( one of the residents was playing the part of Cinderella in the production put on by the Day centre she attended), and the other residents were going to see her; they were going to parties and other social events over the holiday. Two members of staff also completed questionnaires; both of which were positive and they staid how much they enjoyed working at the home, they felt they were supported and encouraged by the manager in caring for the people in their care and said how much they were involved in the day to day lives of the residents. They also said that they had access to good quality training, supervision and annual appraisal and that they discussed their personal development and set goals with their manager. What the service does well: Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 6 The personal, health and social care needs of prospective residents are thoroughly assessed prior to admission to the home ensuring that the residents can be sure that their needs and aspirations can be met. Residents are their family are invited to visit the home before making a decision to move there and that they receive a contract specifying terms and conditions of residency. The care plans are personalised and individually prepared incorporating the complex needs of the particular resident; making sure that they promote independence and choice whilst respecting their dignity and privacy; enabling them to take acceptable risks and make decisions on how to achieve their aims and personal goals. Residents are supported and encouraged to participate in educational, leisure and local community activities within the local area and at various social and holiday venues; enabling them to lead independent and fulfilling lives within and outside the home environs. The manager and staff of the home have the skills and competency to understand and meet the complex health, personal and social care needs of each resident enabling them to maintain their privacy, dignity and independence The home has systems in place to make sure their residents feel safe and protected at all times. The home provides a clean, hygienic, homely, comfortable and safe place for their residents to live in; enabling them to have rooms and facilities tailored to their individual needs. The manager and staff team are trained and supported to have the skills and competency necessary to meet the personal, health and social care needs of the residents; this is evidenced by the policies and procedures relating to recruitment and selection, appropriate training, and effective supervision and appraisal. The residents and staff benefit from efficient and effective management by a qualified, experienced and competent registered manager, enabling the residents to fell safe and secure and the staff supported and encouraged in their work Overall the assessment has identified the service is meeting peoples individual support needs through identified assessments. Through the introduction of the PCP system the persons living in the service have greater control and say what happens in the lives. Staff training needs are identified and action plans are completed to ensure all parties are aware of their responsibilities. Family members and friends are encouraged and supported to be involved in reviews and changes to care provided to their relative through the review process; and with the introduction of the email into the service, the service users are able to correspond to members of family all over the world. What has improved since the last inspection? Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 7 Since the last inspection the refurbishment and redecoration programme has been ongoing , one bedroom was recently done as a nes resident was moving in – he was involved in choosing the colours and what furniture he wanted; three more bedrooms are to be redecorated in the coming year; people who use the service will be involved in choosing colours and furniture. A greenhouse is under construction in the garden and the residents intend to grow more of their own vegetables and fruit for their own use. A new dining room suite and a new lounge suite have been purchased this year. Risk assessments have been reviewed and are to be available in pictorial form. All the residents person centred plans are being reviewed and pictures are being used to help the residents understand what the service does for them, the people who use the service have been instrumental in putting together these plans thereby making sure that their assessed personal, care and social care needs are met how they want them to be and so the staff know how much encouragement and support to give to enable them to lead fulfilling lives. The manager has also used pictures in the homes Statement of Purpose and Service User Guide. The manger has introduced more specialised training for staff and this has been achieved by identifying courses pertinent to caring for the individuals in the home and thereby giving staff specific information on caring for people with complex personal, health and social care needs. What they could do better: This was an excellent inspection and it the home continues to provide an excellent quality service to the people who use the service It is evident that the home manager and his staff are committed to promoting the well being of the residents in their care. The home is to be commended on the excellent range of educational, leisure and social activities offered to the residents; the residents spoken to were very appreciative of the efforts of the manager and the staff of the home to help them enjoy life in and outside of the home. The manager and staff of the home are committed to empowering the people who use the service to have a greater say about their lives and encouraging and supporting them in making choices in their home and community. The people who use the service are to be involved in staff recruitment in the future; this will be achieved through training, PCP Reviews and attending recruitment selection with staff members from the service. The home manager has identified the need for clear communication with Avenues Head Offices to ensure all aspects of the service identified will be achieved, by making sure there is a thorough and effective IT system in the service; this would ensure that there is clear communication with external parties enabling the service to broaden the social network to the people they support to live in their home. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The personal, health and social care needs of prospective residents are thoroughly assessed prior to admission to the home ensuring that the residents can be sure that their needs and aspirations can be met. Residents are their family are invited to visit the home before making a decision to move there and that they receive a contract specifying terms and conditions of residency. EVIDENCE: The service has a statement of purpose file in operation. The statement of purpose file is reviewed regulary to ensure all details are up to date. A pictorial statement of purpose has been put in place to ensure the people supported understand the philosophy of the file and that they are involved in any changes that may need to be made. All visitors to the home have the right to view the file. The service offers a house brochure which explains all about the services provided and how the people who use the service are involved in their home, the house brochure is reviewed by the manager, staff and the people who use the service. The Avenues Trust offers a full assessment for prospective people moving into Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 11 the home. The assessment identifies the correct support package to the prospective person wanting to move into the service; visits are planned for people to see the service and meet the people currently living in the service. The service is supported by Avenues Development and Strategy team to ensure the assessment completed is accurate and the service is able to provide the support package to meet the persons individual needs. Avenues has a admission and discharge policy for the services to follow. During the admission policy the service works closely with the Care Management team from the local borough. Copies of all assessments are kept in the service users PCP Files in section 11. Written contracts for people we support need to be in a format that they are able to understand using communication tools. Makaton, signs and symbols and British Sign Language, video, DVD and compact disc for easy listening Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care plans are personalised and individually prepared incorporating the complex needs of the particular resident; making sure that they promote independence and choice whilst respecting their dignity and privacy; enabling them to take acceptable risks and make decisions on how to achieve their aims and personal goals. EVIDENCE: The service recognises that the people we support currently living at the service or potential persons need to be fully involved with their personal preferences in choice and needs. The service has strong clear principles based on enhancing independence to the persons in the service. The Avenues Trust has introduced Person Centred Plan into the service. The PCP has evolved allowing the people supported to have agreater choice in Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 13 their lives. Staff working at Cowden Road are encouraged to support the service users to their full potential. The PCP Plans are reviewed every six months and the people supported are actively involved from the beginning to the end of their personal review. PCP support plans are devised to identify the people supported strenghts and enhance their quality of life in their home and in the community. Support plans devised are to maintain the skill levels of the individual and to enhance new teaching skills. Support plans over the past 12 months have been put into pictures identified in order to enhance the understanding of the people supported in their home. The service ensures that they find opportunties to talk to the people who use the service to enable them to influence the running of their home and to make suggestions and changes to improve their lives within the home. Each person living in the home has a PCP File with contents specially identified to their individual needs. Holistic profiles are produced with outlines; the profile is a base from which to work from. The holistic profile details all personal history up to date and helps identify the strenghts the person has gained thereby promoting independence through choices made by the individual. Keyworker meetings are held every 6 to 8 weeks to ensure that the people who use the service are encouraged and supported to on track meet their agreed personal aspirations. The PCP tool used in the service is reviewed by the company’s Quality Assurance Department to ensure the PCP system is used correctly. All reviews taken place in the service is reported back to the company senior management team. Action plans are developed if a PCP system is failing in the service. Family and friends and professionals are involved with the person. They are invited to their PCP Review and keyworker meeting they so so wish. PCP Reviews are written in a format that is accessable to the service users if they so wish. The Avenues Trust has clear guidelines relating to the management of finanaces for the people who use the service. The system is inco-operated into the PCP systyem to ensure the service users are able to manage their personal finances with or without support. Risk assessments are completed to ensure the safety of the service user and staff supporting them in their personal aspirations. All staff members are made aware of the confidentiality policy while supporting the people who use the service, this is outlined in their induction into the service users home. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to participate in educational, leisure and local community activities within the local area and at various social and holiday venues; enabling them to lead independent and fulfilling lives within and outside the home environs. EVIDENCE: The service supporting persons living in the home, the team members and the company support and encourage the people who use the service to have a choice and direct control over their networks in the community and to have direct input into their choices in their home environment. The service works closely with Sidcup Adult Education Centre and Bromley Community Café to enhance employment and education qualifications and the Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 15 development of employment at Princess Christian Farm in Hildenborough in Kent. The service support plans are devised to ensure the support team members follow the same support plan these can be supporting individuals in preparing meals, meeting their personal cultural preferences. In the service users PCP files, cultural needs assessments are completed with all the persons living in the service; the completed cultural needs assessments identify the persons diet, food preparation and eating, these assessments are reviewed every 6 months during and after Person Centred Plan meetings. The community leisure facilities are accessed by the people living in the home. These facilities used by the residents promote a healthly life style and maintain links with the local community. Family members are encouraged to maintain an active involvemen with their relative and with the home. The company produces two news letters in which people who use the service are actively encouraged to write about their personal experiences, holidays,day trips, employment and hobbies. Two people living in the home have joined the company football team, their choice is to participate in regular exercise and meet new friends; other residents regularly attend the local church enabling them to participate in their choosen religion. Another of the residents works fo the Shaw Trust and is involved in food preparation, making sandwiches and snacks which are taken by van to local factories and offices, she also attends Sidcup college two days a weeks taking part in jewellery making, pottery, arts and crafts and performing arts. Other residents regularly attend day centres and are involved in lots of different activities and education; one resident enjoys helping out on a farm in kent and is improving his literacy and numeray skills to enable him to help out in the farm shop. The people who live in the home have enjoyed numerous days out and holidays they have visited local attractions theatre, cinemas, shopping centres; they have spent week-ends away and holidays abroad. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager and staff of the home have the skills and competency to understand and meet the complex health, personal and social care needs of each resident enabling them to maintain their privacy, dignity and independence. EVIDENCE: Each person living in the service has personal support carried out by a staff member of the same gender, identified by the shift leader. In service there is a policy covering gender/support staff on induction to the service; new staff read through the policy to ensure they are all following the service users personal support plan Personal support preferences are detailed in the Service user PCP file in section 4. New staff members work along side pernament staff members until the people who use the service and the new staff memberare confident to work together. People who use the service have identified risk assessments completed relaing Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 17 to the use equipment and identifies the immediate dangers and where support is required. The assessments are supported by designated support plans. Service users have moving and handling assessments completed to identify specilalist equipment is required to maintain independence. All staff members respect the service users privacy and dignity at all times. Staff attend training enabling them to give the appropriate level of support and encouragement relating to moving and handling. Staff members receive certificates for all mandatory taraining including food hygiene, health and safety, safe adminisration of medication, first aid and moving and handling, these certificates are kept on the staff members individual personal file. People supported have health care profile which is reviewed every six months; the health care profile contains important information for staff are working with an indivdual with specific needs to be addressed. People living in the home have access to all medical facilities in the community- dentist, opticians, chiropodist, General Practioneer. physiotherapy, psychology other health care professionals are accessed when required. The information relating to medication administered is detailed in the Medication Administration Record Sheet. One person self medicates two risk assessments have been completed and a letter from the GP stating they are happy for the person to self medicate. All staff members administrating medication attend medication training provided by the company. Annually team members have a medication assessment with their line manager. The assessments are available to be viewed by visitors to the service. Medication for the people who use the service is ordered every 21 days. Twenty eight days supply of prescription medication is kept at the service. Household remedy sheets are completed for the service users and signed by the GP. All medicines are handled accordingly to the medicines act 1968 and Royal Pharmaceutical Society and miss use of drugs act 1971. Ordering medication and distribution is completed through the General Practioneer Surgery and the pharamacy working with the service. Staff receive breavement training and care of the dying. Staff members are supported by operational policies to follow. People who use the service have completed funeral arrangements inconjuction with their families. The details are identified in their cultural needs assessment; they have the option to complete a pictorial funeral plan if they so wish. Health care plans are reviewed regularly to identify changes in the health of the people we support. The company has completed a Healthly life style audit in the service. The audit identifies whether or not the service is providing the appropirate care and is accessing appropriate health care facilities in the community. The company has completed a community participation audit to ensure opportunties are being offered to the people living in the home to access the facilities in their local area and that their personal aspirations are being achieved. The house has been identified in meeting all personal aspirations identified with the people using the service. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 18 Regulation 26 audits are carried out monthly to ensure the service is maintaining standards in the provision to support provided in the service. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has systems in place to ensure that the people who use the service feel safe and protected in and outside the home. EVIDENCE: The Avenues trust employs a Behaviour support manager that the service has access to at the Avenues head office. The manager will visit the service and offer support and advice to the people who use the service and to the staff team. The London Borough of Bromley offer access to their Community Learning Disability Team who offer advice and support to the individual in the home. The Avenues Trust has a complaints procedure in picture and audio format to be accessed by all parties involved supporting the service user; staff and service users are shown how to use the procedure when required. A Whistle Blowing Policy is in place alongside a complaints and grievance and disciplinary policy. The policies are kept in manuals in the service. A copy of the complaints procedure is kept in the office also a copy is available to be viewed by the service user in their service user guide which is kept in their personal bedrooms. Copies of the procedure can be accessed on the service computer to which the service user can access with support from the team, family member or advocate if they so wish. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 20 Complaints are monitored by the company, as part of the quality audit process; adult protection cases are monitored by the management team on a monthly basis. People who use the service have the opportunity to voice the concerns through meetings where they are able to express their likes and dislikes about living in their home. The service provides a complaint and compliment book in which families, professionals and friends/advocates are able to access. The book is reviewed during a monthly audit. All team members in the service have attended Safeguarding adult training. Team members attend a refresher course every 2 years. The service has a copy of the No Secrets document. Regular Staff supervisions and team meetings are held monthly to discuss any potential problems. All new staff employed will have been checked against the POVA and enhanced CRB. All staff members have a handbook and GSCC guide lines which gives clear and precise understanding of the companies procedures. Where a service has restraints in place risk assessments are completed and reviewed regularly. Family members, Health professional, advocates etc receive a Stakeholder questionnaire from the company where they are able to express their views about the support being delivered at the service. Copies of the questionnaires can be found in the Avenues Quality Audit file kept in the service. People who use the service can be confident that their financial affairs and monies are kept secure. Documentation is kept and audited each month to ensure all safety procedures are in place. House Manager are restricted to the amounts they can authorise in transactions in the service. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service provides a clean, hygienic, homely, comfortable and safe environment for the people who use the service to live; ensuring that they have a place and facilities that are tailored to their assess personal, health and social care needs. EVIDENCE: The service contains a fire file where all relevant details can be found about the people we support and the service. The contents of the file are service user personal details, fire risk assessments plans of the service and procedures to follow in the event of a file. The file is reviewed regularly to ensure all details updated when changes have been identified. The doors in the service are connected to magnetic door releases. In the event when the fire panel is activated the doors close automatically and give protection. Fire alarm test are completed weekly and events are recorded. Fire Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 22 drills are practised monthly and events are recorded. Emergency lighting system is checked monthly. All fire and lighting system is serviced quartely except the fire extinguishers are serviced annually. Night call alarms are provided in the service users bedrooms the call alarms are raised on an internal pager to notify staff who has activated the system. The call alarms are tested monthly. Details of bedroom call numbers are displayed on the notice board in the office. All certificates for all fire appliance system are located in the fire file. All dirty or soiled clothing are transported to the utility room in colour coded bags. Bags are provided for clinical waste where an external lockable bin is provided. The clinical waste is collected by a desiginated waste collection company identified by The Avenues Trust. All rooms in the service which have hand washing facilities have hand soap dispencers to promote personal hygiene and prevent infection. Risk assessments are completed in the household for service users, staff and visitors. the assessments are reviewed every 6 months or sooner Legionella water tests are completed twice a year in the service to ensure the water provided is safe forconsumption in the service. A certificate indicates the water is Legionell Disease free. The certificate can be viewed in the Avenues Quality file. Rooms that are vacant the water taps are turned on regularly to ensure no water is laying in the pipes to prevent contamination with the copper pipes. Water temperatures are checked monthy to ensure all water consumed in the service is within the legal guidelines. All hand basins, baths and showers are fitted with care mixer valvers, except the kitchen and utility rooms. Installation of the care mixer valves ensure hot water used in the service doesn’t exceed 43 degrees and cold water is below 20 degrees. Monthly Health and Safety checks are completed monthly through out the service. All areas of concern are reported immediately to the house manager or the health and safety representative for the service. Staff on duty report maintenance issues to the housing association maintenance department for action. Health and safety check lists list are clear indicators to the performance being delivered in the service. Works orders are received from the maintenance department. Upon complection of the work the works oder is signed and dated by staff in the service. People we support are encouraged to report any concerns for health and safety and reported to staff members on duty for immediate action. Gardening equipment used by people we support is risk asssessed . All equipment is stored in a locked external shed. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager and staff team are trained and supported to have the skills, experience and competence necessary to meet the assessed personal, health and social care needs of the people who use the service; this is evidenced by the policies and procedures relating to recruitment and selection, appropriate training and effective supervision and appraisal systems. EVIDENCE: The Avenues Trust has a comphrensive training portfolio which enables the staff to gain relevant experience and knowledge to support them in their work positions.Each staff member employed at the service has a monthly supervision with their line manager, the time allows both parties to discuss issues in the work place. Training is identified for the staff member and the reasons for the course attendance. Each staff member has annual performance review to identify work progression and identify personal goal action plans for development over the next 12 months. Performance objectives reviewed quartely to ensure the targets are being Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 24 achieved and shortfalls / resources are being met. Staff members have access to different learning methods open learning work books and computer based training. Staff members employed in the service are continiously learning, coaching and mentoring delivering the ongoing support creating a team that is highly developed in delivering a high quality service. All staff members are encouraged to identify training for themselves to develop personal skills. Staff members employed at the service are required to have two references and previous employment records are checked. All staff members must be cleared by POVA and CRB before commencing in the service. Staff members receive a copy of the code of conduct and practice set by the GSCC available to them. Contracts are given to staff members outlining work practices and employment. All staff members appointed are subject to a six month probation period completed by their immediate line manager. During the six month period the staff member has to attend statutory and non statutory training The staff has to complete identified training within the first six weeks of employment. Induction packs are handed to staff members to be completed and signed by the induction member and their line manager. Induction work books being completed by new team members are Learning Disability Qualification. Each service has an identified member who is a mentor and trained by The Avenues Trust. The mentor in service supports the new team member through theire work book along with support from line manger, and team members. Some parts of the work book involve the people supported in the home. Upon complection of each work task in the work book this is then assessed by an external assessor employed by the company to evaluate the work complete and liaise with the candidate and mentior. When the work book is completed all areas have been completed. The LDQ work book is sent away for for marking with an external company. The work book completed counts as part of the staff members probation period complection. Staff members are encouraged to undertake NVQ qualifications level 2 support team, level 3 senior support team and level 4 for managers and above. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use the service and the staff of the home benefit from effective and efficient management by a qualified, experienced and competent registered manager; enabling the people who use the service to feel safe and secure and the staff to feel supported and encouraged in their work. EVIDENCE: Responsibility of the house manager is to ensure all new staff members are inducted into the service of employment. New employees are on a 6 month probation period. Upon complection of the probation period the employee will meet with their line manager and discuss their work progression before being signed off. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 26 New staff members attend identified training within the service. Statutory training has to be completed within the probation period. Staff members are shown access to the companies policies and procedures to support work allocation through their training and operational conduct in the service.Training completed meets the standards outlined in TOPSS and LDAF. Certificates kept in the service outline all equipment has been safely checked by a qualified professionals and deamed safe to use. Legionella testing is carried out every 6 months, certificate obtained state the water supply in the service is safe for consumption. Monthly Health & Safety checklists are completed, the service has an identified Health & Safety Representative. All staff members participate in the monthly audit to raise awareness. Risk assessments are completed in all areas of the working environment. Chemicals used in the service are supported by COSHH guidelines. The Health & Safety Representative attends training with the company with the companies Health & Safety Advisor. Relatives, Health Care Professionals, advocates are sent stakeholder questionnaries to detail the support services offered to the people living in their home. The stakeholder questionaires indicate if external parties are satisfied with the development of the persons being supported in their home environment. People who use the service have 6 monthly PCP Reviews where all parties involved are invited, PCP Reviews allows the service user to have a clear say in their lives, PCP Reviews completed are supported by keyworker meetings which are held every 6/8 weeks. All persons supported in the service have their own individual PCP files relevant to their support requirements in their home. People we support are encouraged to advocate their personal views during audits Regulation 26 with the visiting officer. Details of the audits can be found in the Avenues Quality File. Service Reviews are held quartely to ensure the service is meeting the guidelines set out by the company and CSCI. Avenues produce an annual survey where all staff members are invited to participate. The service has an annual visit from CSCI recommendations and requirements need to be actioned, timescales set and persons responsible. It is the responsibility of the house manager to ensure all action plans are achieved. Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 4 3 4 4 4 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 4 32 4 33 4 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 4 4 4 4 4 4 4 4 Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cowden Road, 52 - 54 DS0000006911.V373211.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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