Inspection on 16/06/08 for 10 Whitfield Avenue

This inspection was carried out on 16th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

10 Whitfield Avenue 21/11/06

10 Whitfield Avenue 08/11/05

10 Whitfield Avenue 06/06/05

10 Whitfield Avenue 14/12/04

10 Whitfield Avenue 07/06/04

10 Whitfield Avenue 12/01/04

Similar services:

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

1a White Ladies Close

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 10 Whitfield Avenue Seabridge Newcastle Staffordshire ST5 2JH Lead Inspector Karen Powell & Rebecca Harrison Unannounced Inspection 16th June 2008 10:20 10 Whitfield Avenue DS0000005111.V366139.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 10 Whitfield Avenue DS0000005111.V366139.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. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 Whitfield Avenue Address Seabridge Newcastle Staffordshire ST5 2JH 01782 638291 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) whitfieldave@choicesha.co.uk Choices Housing Association Limited Miss Rosanna Sarah Zacune Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Whitfield Avenue is a three bedded, semi-detached house located in a residential area near Newcastle town centre, to which there is a frequent bus service. Retail outlets nearby include a number of shops and a mini market. There are several public houses close by that are popular with residents. The home offers accommodation for up to three persons between the ages of 18 and 65 (all of whom are currently male), who have differing degrees of learning disability. On the ground floor there is a large tastefully decorated and furnished lounge with comfortable seating, one single bedroom, a kitchen, a dining room come conservatory and a WC. The first floor comprises of two further single bedrooms, a bathroom/shower and WC and the office/staff sleeping in room. There is a large private garden to the rear, where the residents use the summerhouse as a clubhouse in good weather, having been furnished with all the necessary facilities for music, games and a mini bar. The small formal garden at the front includes a paved area for parking one vehicle. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged were not available in the Service User Guide as required therefore the reader may wish to obtain this information direct from the service provider. 10 Whitfield Avenue DS0000005111.V366139.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 three stars. This means that people who use this service experience excellent quality outcomes. The inspection was unannounced and took place on 16th June 2008 by two inspectors over three and a half hours. A range of evidence was used to make judgements about this service to include discussions with people who use the service, staff on duty, two surveys we received from service user’s and one from a member of staff, a tour of the home, a review of the homes quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records held on behalf of two people, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the manager for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. Some of the manager’s comments have been included within this inspection report. The purpose of the inspection was to assess all ‘Key’ National Minimum Standards for Younger Adults and any additional Standards considered necessary. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The home is managed in the best interests of the people living at Whitfield Avenue. The manager has a clear vision for the service and is well supported by her team. Staff spoken with considered the service is well managed and that the manager is open, approachable and service user focused. The home is spotlessly clean and well equipped. Soft furnishings are of good quality and provide people with a comfortable and homely place to live. People have personalised their own bedrooms and it is evident that staff respect people’s own space. People told us that they like living at Whitfield Avenue and enjoy looking after their gardens, which are beautifully presented. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 6 Staff have developed positive working relationships with the people they support, their relatives and other agencies. The people living at the home told us that they get on well with the staff and that the manager is great. Each individual has their own person centred plan, which focuses on their strengths and personal preferences and contains a range of information that is very important to them. People told us that they have residents meetings to discuss things important to them and that they are given good opportunities to make choices and take control over their lives. A survey completed by a member of staff considered the home does the following well: ‘Training. Person centred approaches. Skill mix in relation to service users and staff. Utilising individual strengths and supporting staff’ What has improved since the last inspection? What they could do better: The findings of this inspection evidence that people living at Whitfield Avenue are provided with excellent outcomes and the service continues to perform well. No requirements or recommendations have been made as a result of our inspection. It is hoped that the service can sustain its performance and continue to provide positive outcomes for the three people living at the home. A survey that we received from a member of staff felt the service could improve by increasing the mileage allowance given to staff. The self-assessment that we received from the manager was detailed and reflects both the strengths and areas for continued improvement and comments include: “Continue to improve the involvement of service users to lead the quality assurance process.” “Improve awareness of all aspects of budget management within the home.” 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 7 “Respond to new safeguarding adults legislation by incorporating into existing training.” 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. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 8 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 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 9 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 and 2 Quality in this outcome area is excellent Prospective people looking for a residential service are provided with all of the necessary information to help them make an informed decision about whether Whitfield Avenue will meet their needs. The service has assessment and admission processes in place to enable the successful admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a detailed Statement of Purpose in place and a pictorial service user guide, which can be made available in other formats on request. Both documents are very specific to the people who live at the home and produced to a high standard. The manager was advised to ensure fees charged are included in the guide, as required. There have been no new admissions to the service since the last inspection however assessment procedures were considered satisfactory at previous inspections and are included in the Statement of Purpose. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is excellent Support plans are detailed, regularly reviewed and provide staff with sufficient information to meet people’s individual needs and achieve their personal goals. People living at Whitfield Avenue are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at all records held on behalf of two people living at the home. Support plans were available on both files examined and contained detailed information of need and level of support required. Each individual has a person centred plan, which focuses on the individual’s strengths and personal preferences and contains a range of information important to each individual. All staff sign to say they have read the information and these are reviewed at the required frequency with significant others and focus on questions about what has worked, progress and achievements and future plans. The minutes of a recent resident meeting evidenced that person centred plan files were 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 11 discussed with all three people who use the service and people were informed that they have control over these. One person told us that he sees his file when he wants. Guidelines to support identified behaviours were available and found very detailed and records seen evidence that behaviours are monitored and evaluated. Observations made during the inspection indicate that people are able to make decisions for example people were seen to select their own choice of lunch. People told us that they have residents meetings to discuss things important to them and minutes of the most recent meeting were seen and items discussed include the service user guide, care files, domestic tasks, a grumble book and issues identified relating to health and safety. It was reported that none of the current people have an independent advocate but do have access to an advocacy service if desired. Named care workers act on behalf of service users and work in their best interests in addition to the relatives of two people The management of risk is detailed in the homes Statement of Purpose and states ‘A reasonable degree of calculated risk is a necessary accompaniment to person development. Staff will work with service users to promote their ability to exercise informed choices and to measure risks involved in particular courses of action’. Assessments to support people with taking responsible risks were available on both files examined with evidence of review. These covered accessing the community, activities, daily living tasks, behaviour management, nutrition, personal care and finances. The file for an individual who absconds also included possible consequences when leaving your home and stranger awareness that had been developed in a pictorial format. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good People living at Whitfield Avenue are provided with good opportunities to develop and maintain their social and recreational interests and are enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we arrived at the home two people were leaving to attend their work placements and the third person was going out with the staff to the head office. All three people returned around lunchtime and told us where they had been and it was evident that the two people enjoy their work placements working in the community. One person said ‘I work in a charity shop and like it, I also deliver newspapers on a Sunday’. It was reported that two people also work for the company and receive payment for dealing with minor repairs. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 13 Another person gets paid for cleaning a vehicle at a nearby home managed by the provider. The manager reported that people no longer access college courses through choice although they have previously attended college. This was confirmed in discussions held with one person who said he prefers work now. Life Experiences Assessments were available on the two files sampled and are completed with staff and focus on areas to include home, leisure, relationships, freedom and opportunities. Theses are completed on an annual basis and an overall score given based on what individuals do and were positive. Although people do not access day services discussions indicated that people lead active lifestyles although one person said that he would like to do more walking but enjoys helping out around the home. Two people are able to go out independently based on an assessment of risk. Lots of photographs of likes and dislikes were seen on one of the files seen and another person has a photo board to correspond to his chosen tasks. One person showed us the daily activity and support plan displayed in the kitchen for each person, which includes tasks to be completed. The Statement of Purpose states ‘Personal relationships are a fundamental area of everyone’s development’. The manager gave examples of how family support is encouraged for two people who have regular contact with their family. One person told us he sees a lot of his girlfriend, which is important to him. People also said that they are looking forward to a coffee morning arranged for July. People’s rights and responsibilities are included in the Service User Guide in addition to rules for the home and were discussed at the most recent residents meeting. People are involved in the domestic routines of the home and take responsibility for their own room in addition to shopping, meal preparation, cooking and cleaning. The people we spoke with said they like helping out. Bedrooms doors are lockable, each person is provided with a key. One person showed us the menu and discussions with him and another person indicated that everyone helps plan, shop and prepare the meals with support. The menu looked balanced and varied and a healthy diet is promoted. Records evidence that people are reviewed annually by a dietician and weighed monthly and outcomes recorded. One person is a member of a slimming club. People told us they like the meals and enjoy preparing them. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 21 Quality in this outcome area is excellent The health and personal care that people receive is based on their individual needs, which are closely monitored and reviewed. The principles of respect, dignity and privacy are put into practice. People living at Whitfield Avenue are safeguarded by the home’s systems for handling, storing and administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preferences in relation to support requirements were available on both files examined and evidence that people are encouraged to maintain as much of their independence as possible. The person centred plan described support needs and includes information on how to stay healthy. The statement of Purpose includes the promotion of privacy and dignity. Each person has a detailed health action plan in place, which has been completed in a pictorial format and clearly evidence that people living at Whitfield Avenue see a range of health and social care professionals. All health appointments are recorded in addition to outcomes and a monthly evaluation 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 15 plan is completed which details current medication, number of times PRN (as required) medication has been administered and reasons stated, accidents, and all health appointments. Medication arrangements within the home were seen to be satisfactory. Two people self administer their medication following an assessment of risk. One person told us how he looks after his tablets and that he signs his own medication administration record and staff monitor this. A protocol is in place for medication given when required, for example tablets for a headache and this has been sign by the doctor. A member of staff reported that five staff had received accredited training and the others training provided in-house. We did not review the homes medication policy on this occasion however a member of staff spoken with felt that procedures safeguard people living at the home. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Procedures are in place to safeguard people using the service from potential abuse and staff receive the necessary training to ensure people are not placed at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People have access to a complaints policy and procedure, which is available in a number of formats and appropriate to the needs of the people using the service. A ‘Grumble book’ has been introduced which is kept in the office for people who use the service to share a disagreement with staff in confidence. Surveys received and discussions held with all three people evidence that they have an understanding of what to do if they were unhappy with the service. One person said ‘I would speak to the staff’. Relatives who had completed a satisfaction survey sent out by the home this month stated they knew how to make a complaint if they had to. We have not received any concerns or complaints about Whitfield Avenue since the last inspection on 21st November 2006. It was stated on the AQAA that staff have received training in adult protection and updates are provided when necessary, certificates were seen on individual training files examined by us. We also saw certificates in the management of actual and potential aggression; the manager confirmed she had updated hers 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 17 in May 2008. As previously stated the home has very detailed behaviour management plans in place for when or if individuals challenge the service. Any incidents are clearly recorded and records available for violent incidents and any interventions. Staff receive training in physical intervention. Staff spoken to told us Choices provide excellent training opportunities. The home has access to the local safeguarding adults policy and procedures. Detailed financial profiles were available on the two files examined, which provide a good overview to the understanding and level of support a person requires with managing their money. Risk assessments have also been developed and money and valuables are stored in line with the organisations policy on ‘finance and valuables’. One person showed us how he looks after his own money, which is monitored by staff. He said that he has his own bank account and takes out his own money and that both he and a member of staff check his money and sign to say how much he has. It was evident that he takes great pride in looking after his own money. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent People who live at Whitfield Avenue are provided with very homely, clean and well-maintained place to live and are protected by the good infection control procedures in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located in the Thistleberry area and provides good access to community facilities and services and just a short distance from Newcastle Town Centre. Accommodation is provided over two floors and is appropriate for the particular lifestyle and needs of the people living there. The first floor provides two single bedrooms, a staff office/sleep-in room and a large bathroom. Shared areas include a lounge, kitchen and conservatory. A third bedroom is provided on the ground floor. All three people were happy to show us their bedrooms, which are very personalised and reflect individuality. One person showed us his various items of sensory equipment to help him relax. Discussions with people who use the service clearly evidence that they are encouraged to see the home as their own which is very well maintained and 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 19 decorated and furnished to a high standard. People told us that they like living at Whitfield Avenue. People using the service help maintain the gardens, which are beautifully presented and well stocked. The Manager stated that forthcoming plans include the redecoration of the lounge, kitchen and conservatory and repainting of external paintwork. The home was exceptionally clean and tidy throughout and people who use the service are encouraged and supported to maintain their home. Personal protective equipment was readily available and substances hazardous to health appropriately stored. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is excellent. People who use the service are supported by a committed staff team who have a good understanding of the needs of the people they support. People are safeguarded by the organisations robust recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen to interact with service users in a positive manner throughout the inspection and observations made clearly evidence that staff have developed positive working relationships with the people they support. It was stated on the AQAA that seven permanent staff are employed at Whitfield Avenue. Since completion of the AQAA one member of staff has transferred to another Choices home, this leaves one vacant post. All staff have completed NVQ level 2 or above. This exceeds national minimum standards. Staffing levels were discussed with the manager and the duty rota examined. The home is staffed to meet the current level of need of the people living at the home. The duty rota reflected this and was accurate on the day of the 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 21 inspection. During the night the service provides one member of staff who sleeps in. This is to cover any emergencies that might occur. There is a robust recruitment procedure in place. We looked at the file of the newest recruit to work at the service. This contained all the relevant preemployment checks required by regulation. It was stated on the AQAA staff performance is reviewed by annual appraisal. We examined too long serving employees files and found completed appraisals. Staff consulted as part of the inspection process said they receive ongoing support from their manager. All new staff undertake induction training with ongoing reviews and end of period assessment. We saw evidence of completed workbooks for the newest member of staff. Further training needs are identified and planned within the annual training plan, which is tailor made to incorporate the needs of the service in addition to mandatory training requirements. All staff have three monthly appraisal reviews and a personal development plan. As stated earlier staff consulted with as part of the inspection process told us that training opportunities are good. We saw training certificates for all mandatory training topics including moving and handling, health and safety, medication, origins of behaviour and behaviour management, fire safety, personal safety and lone working, managing actual and potential aggression and safeguarding adults training 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. Whitfield Avenue is effectively managed in the best interests of people using the service. The home has effective quality assurance systems in place to assess performance and evaluate outcomes for people using the service. The premises are managed and maintained in a manner, which ensures the safety of people using the service and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 23 Miss Rosanna Zacune is the registered manager of the service she is a registered mental health nurse holds the registered managers award, is an NVQ assessor, managing actual and potential aggression trainer, moving and handling trainer, facilitator for sexuality and inter personal relationships and holds the learning and assessment in practice award. She has many years experience in working in the care sector and has attended training courses relevant to her role. Discussions with her evidence that she has a clear vision for the service, which she has effectively communicated to the people using the service, relatives and staff. The deputy manager contributed to the inspection process and shared with us that the senior management team work well together along with the support worker team. Monthly visits required by Regulation 26 are undertaken and detailed reports of the findings were available for inspection. A recent restructure in senior management has taken place. There is a quality manager post and a business development manager post. Support to Miss Zacune on a one to one basis has not yet been clarified; whilst this does not pose an issue to Miss Zacune arrangements will need to be clarified. The self-assessment that we received from the manager was detailed and reflects both the strengths and areas for continued improvement and comments include: “Continue to improve the involvement of service users to lead the quality assurance process.” “Improve awareness of all aspects of budget management within the home.” “Respond to new safeguarding adults legislation by incorporating into existing training.” The service has satisfactory health and safety procedures in place. Service certificates were readily available in addition to risk assessments and other safety records required. It was reported there have been no fire service visits or environmental health inspections since the last inspection. Issues pertaining to health and safety are discussed with people who use the service through regular residents meetings. 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 24 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 x 4 x 5 x 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 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 4 33 x 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 x 4 x 4 x x 4 x 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 10 Whitfield Avenue DS0000005111.V366139.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!