Inspection on 17/06/08 for 19 Beech Avenue

This inspection was carried out on 17th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Beech Avenue 10/08/09

19 Beech Avenue 23/03/07

19 Beech Avenue 31/05/06

19 Beech Avenue 09/02/06

19 Beech Avenue 26/10/05

19 Beech Avenue 19/11/04

19 Beech Avenue 17/05/04

Similar services:

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

Ruskin Lodge

Clover House

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

CARE HOME ADULTS 18-65 19 Beech Avenue Smithfield Egremont Cumbria CA22 2QA Lead Inspector Liz Kelley Unannounced Inspection 17th June 2008 10:00 19 Beech Avenue DS0000022536.V366119.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 19 Beech Avenue DS0000022536.V366119.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. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Beech Avenue Address Smithfield Egremont Cumbria CA22 2QA 01946 824885 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) beechavenue@walsingham.com www.walsingham.com Walsingham Ms Judith Elizabeth McCartney Care Home 8 Category(ies) of Learning disability (8), Physical disability (5) registration, with number of places 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 8 people over 18 years of age with a learning disability (LD) of whom 5 may also have a physical disability (PD). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 23rd March 2007 Date of last inspection Brief Description of the Service: Walsingham provide the services and care at 19 Beech Avenue. Eight service users who have a learning and physical disability can live in this home. The home is located in a residential area about one mile from the town of Egremont on the West Coast of Cumbria. Operating as one unit, it comprises of a bungalow and adjoining house. Both properties are linked by a covered and secure walkway. The properties blend in naturally with the immediate area. All private bedrooms are for single occupancy. Those in the bungalow all have en-suite shower, toilet and washing facilities. There is a range of adaptations and specialist equipment available. The bungalow is designed to enable service users who use wheelchairs, and who may need additional support to move around with ease. The current fees for the home range from £548 to £967 per week. Information about the service is supplied to new and prospective residents in the service user guide. Inspection reports are made available to residents and their representatives and are displayed in the home. 19 Beech Avenue DS0000022536.V366119.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection visit took place over one day. We (Commission for Social Care Inspection, CSCI) spent time with people living in the home and talking to them about their experiences. We also met with staff on duty and looked at records relating to the running of the home and how people like to be supported to live their lives. We also sent out surveys as part of this inspection to get feedback from people living in the home, their relatives and representatives and other professionals involved with the home. Before the visit the manager completed an Annual Quality Assurance Assessment (AQAA), which provided information about all aspects of the running of the home. This included a self-assessment against the National Minimum Standards (NMS), recording what the home does well, what has improved and plans for the future. On the day of the visit six people where at home and the house had a lively and friendly atmosphere with people busy having lunch and spending time with staff in their own rooms, and going out for walks. Two other people later returned from a music class. The overall picture gained by the Inspector was that despite problems with staffing shortages staff were doing their best to offer an individually tailored service. What the service does well: People are enjoying a good quality of life and leading an active and fulfilling lifestyle by staff being creative with their time and resources. They are supported to pursue their interests and hobbies and have a good social life where they are able to mix with their peers and maintain friendships. They regularly access the facilities and amenities of the local community. Each person has a detailed healthcare plan and individual risk assessments to enable them to stay safe and well whilst leading normal lives. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s individual needs and preferences are assessed to ensure a suitable service can be provided. EVIDENCE: The AQAA told us that: We could improve our service user guide into easy information format, to ensure that potential residents could make an informed choice. We plan to improve the service user guide, and to ensure that all the people we support are given the opportunity to live where they wish. People’s individual needs and preferences are assessed to ensure a suitable service can be provided. The manager had recently arranged for residents in the house to be reassessed by a socialworker in order to assist them in making future plans and decisions on where they would like to live and with whom. All the residents have an up-to-date contract of terms and conditions, in a user-friendly format, signed and agreed by them or their representative and held on their personal file. This is good practice in ensuring people are fully informed of their rights and obligations. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 9 The organisation informed us that they have planned training for managers in carrying out and assisting in assessments to ensure people are appropriately consulted and best matched to the resources of services in order that their needs can be met. 19 Beech Avenue DS0000022536.V366119.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 good. This judgement has been made using available evidence including a visit to this service. People are enjoying a good quality of life through the support of the staff team and the use of person centred plans. EVIDENCE: The recording of information relating to people’s personal and healthcare needs has improved. The introduction of person centred support plans gives staff a better understanding about the person and how they prefer to live their lives and what support they require. The staff team develop comprehensive care plans that include detailed information about a person’s life and what is important to them. They contain information relating to significant events in people’s lives; an informative pen picture; how people like to spend their time; important relationships; communication needs; support needs; religious and cultural needs. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 11 Daily care notes and diary recordings make sure there is an accurate record of the care and support provided and significant events and activities. This ensures a good continuity of care among the staff team and keeps people up to date with any changes. These are then recorded and monitored on an ongoing basis. A good range of risk assessments have been completed that support an independent lifestyle whilst safeguarding both the individuals and staff. These have been kept under review and updated as the need arises. The AQAA describes recent developments: We have established communication boards as a result of Person Centred Thinking practices, and changed the way we work as a team to respond to the requests of the people that we support. For example, we do not have fixed routines; we adapt and change our practices in line with the need of the individual, using our creativity and judgement to guide us. These developments were seen on the Inspection, for example a communication Board were displayed in bedrooms which gave helpful hints and information about a people with no verbal communication. A style of reviewing care plans was noted that used symbols as a key for what was working well and what needed to be changed to help a person meet their goals. These could be further strengthened by leading onto an Action Plan with dates and who was responsible for the actions. The manager has arranged for the staff team to receive further training on Positive Communication to assist them even further with people who have no means of verbal communication in an aim to be even more responsive to their needs. 19 Beech Avenue DS0000022536.V366119.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): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are trying their best to support people to live interesting and individual lifestyles within a group setting. EVIDENCE: This is possible through the attention to detail in drawing up a person centred care plan and in then carefully monitoring changes and developments. People are supported to pursue their interests and hobbies and have a good social life where they are able to mix with their peers and maintain friendships. They are able to access the facilities and amenities of the local community. People follow interests and hobbies and go on regular holidays. However this is often dependent on the availability of staff. The AQAA states: We have made successful attempts at enrolling people on F.E courses and found accommodation abroad for holidays that cater for people with profound disabilities. We have also increased the familial connections for some people. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 13 The use of person centred plans ensures that each individual has a tailor made plan which includes details of their background, family, past interests and has very good detail on a persons likes, dislikes and their future aspirations. For one resident this has had a positive outcome of staff getting to know of a favourite family holiday destination, and they are now helping to organise a trip there. Another resident attends a local college and is trying out new courses. Staff shortages have caused problems for people to get out as much as they would wish and the staff have looked for ways to involve them in the home mainly through one to one contact, conversation and carrying out daily tasks, such as frequent trips out to undertake everyday activities, such as shopping, banking etc. The AQAA states: As a staff team we need to recruit to our full establishment figures and use less agency support. As we state later in the staffing section of the report, while the home continues to be under staffed this will hamper fully implementing person centred plans. For example staff stated that people had to agree to do the same thing to be able to go out, and sometimes could not go out at all if staff were required elsewhere in the home. On the day of this visit six people where at home and the house had a lively and friendly atmosphere with people having snacks and spending time with staff. One person was having their clothes and drawers sorted and was being included by staff who constantly included this person in what they were doing. People are supported to maintain and develop relationships, with relatives and friends. Some people are supported to visit their families. The home supports this with sensitivity and respect of each family’s circumstances. Relatives who returned comment cards as part of this inspection all commented positively on the support their relative receives from the staff team. The person-centred plans show how staff support people to maintain important relationships. The meal arrangements are very flexible and staff are able to respond to individual requests. Menus and records sampled demonstrate that meals are of a good quality, and provide good nutritional value. The weekly menu is planned with residents, as appropriate, and shopping is carried out with residents who take turns. Individual shopping is also encouraged to develop independence and daily living skills. Residents also enjoy a variety of Take Aways and meals out. Staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with meals. They are aware of the importance of going at the pace of the resident, making them feel comfortable and unhurried. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each persons health and medication is carefully monitored ensuring that they have access to services that help to maintain good health. EVIDENCE: Based on discussions with staff and visiting healthcare professionals, observations of the staff, and also from the written records, people receive appropriate support to access the health services they require. Staff have a good understanding of residents healthcare needs. The staff team work positively with local health care professionals to offer a responsive and supportive approach in assisting people to maintain their health. Records on healthcare needs are well maintained and kept up-to-date, these are linked to care plans to alert staff on any changes, and include monitoring sheets for specific issues. The home has sensitively handled the ageing process and offers good support to minimise any impact on independence. The staff team are managing complex healthcare issues, as demonstrated on the day of inspection when a resident was being carefully monitored across a 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 15 period of illness. The protocols in place had been developed in conjunction with this persons’ GP, and staff were observed to follow these to ensure that the person was safe and well cared for at all times. The senior was in regular contact with the GP across the day to seek advice and a visit was arranged for later in the day. Interactions were observed between staff and residents and this was carried out in a sensitive and respectful manner. Residents are registered with a GP of their choice and have access to other members of the Primary Health Care team. Other checks such as opticians and dental checks are also recorded on Healthcare files. Any personal care is delivered in residents’ own bedrooms, and staff are aware of issues of dignity and privacy. For example this was well written up in the instructions for staff in using a hoist and how to best retain peoples dignity. We examined medication records and the contents of the medication cabinet and on the whole these were well maintained ensuring people were being given appropriate support and guidance with their medication. Introducing an audit trail and regular spot checks to ensure the home has the correct amounts of medications at any one time would further strengthen the systems. There was some evidence of over ordering leading to more than one medication packet and bottle being open and used, making it difficult to be accurate about exact levels of medications in the home. 19 Beech Avenue DS0000022536.V366119.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 adequate. This judgement has been made using available evidence including a visit to this service. The written policies and procedures for safeguarding people have recently improved but further training is necessary to ensure that staff understand and follow these steps in order to protect people. EVIDENCE: The organisation, Walsingham, have responded to criticisms of mismanagement in safe guarding people with an action plan to address these failings which was introduced in November 2007. A large part of this action plan was to ensure staff have training in safe guarding vulnerable adults. The policies and procedures for safe guarding people have also been revised and updated and staff have had these explained to them in team meetings and supervisions. Very recent evidence indicates that the latest reportable incident has been referred to social services. However up until the beginning of June a series of incidents were not reported demonstrating a lack of understanding of this important area despite its high profile in the home. The home is required to produce and submit a training plan and profile for the staff team to CSCI to demonstrate training and competency in this, and other areas. The AQAA states: We could improve the complaints procedure into easy information format, however it is difficult to gauge if this would improve their awareness of the procedure. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 17 In light of the Mental Capacity Act the home needs to review the people living in the home with regard to their capacity to make decisions and set up support for those requiring an advocate to represent their best interests, or assistance in making complaints. Where appropriate this should be documented as a support need in a persons care plan. The staff team are due to have training in managing aggression and breakway techniques for challenging behaviours. The information regarding this course appeared to be directed at NHS staff dealing with violent outburst from patients. The manager needs to ensure that this course is appropriate for supporting people with a learning disability and that it complies with the guidance issued by CSCI professional website. This states that “Training in physical interventions should be accredited by the British Institute for Learning Disabilities (BILD).” 19 Beech Avenue DS0000022536.V366119.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, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, homely and comfortable environment that match their lifestyle needs. EVIDENCE: The Home is in the heart of a well-served community being on a housing estate on the outskirts of Egremont, and is similar to the surrounding properties. The furnishings and decoration are of a good standard and homely in style. The gardens have been made attractive through the efforts of staff to plant up flowerbeds, and a large paddling pool was purchased recently during a hot spell. Resident’s individual bedrooms are of a good size and individualised to each persons tastes and interests. Those in the bungalow are all ensuite with shower facilities. All the bedrooms in the bungalow have recently been redecorated. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 19 The home has good facilities for assisting people with limited mobility, such as an assisted bath, walk-in showers and electric beds. The organisation has just made a considerable investment in over head hoists for all bedrooms in the bungalow. On the day of inspection the home was orderly and clean, and is well maintained to ensure the safety and well being of people in the home. The Home meets the requirements of the Fire and Environmental Health services and has a maintenance and renewal programme to ensure that residents live in a safe and well maintain home. 19 Beech Avenue DS0000022536.V366119.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, 33,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are improving which is leading to more quality time being spent with people living in the home. EVIDENCE: At the last Random Inspection (November 07) the home was experiencing staffing shortages but had managed to cover shifts by using agency workers, and by staff doing 6 shifts instead of five. In the last year the home has been down by 4 to 6 full-time staff. Agency hours have been as high as 80 to 100 per week. Since then permanent staffing levels have improved reducing the need for such a high reliance on agency staff. This promotes better consistency of care for people. The organisation has developed a number of initiatives and recruitment drives to attract new staff. This momentum needs to be kept up to fully staff the home. Until new staff are in place and are fully inducted into the home this will impact on peoples opportunities, for example this is particularly effecting peoples ability to have trips out. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 21 Three new staff have been employed with a further two awaiting a start date following checks. This should lead to more quality time being spent with people living in the home. All staff are required to go through a thorough recruitment process that ensures all the necessary checks and references are in place therefore safeguarding the people living in the home. They are issued with suitable contracts of employment and job descriptions when appointed and must complete suitable induction training. The manager must now produce a training and development programme that will ensure staff receive suitable levels of training in line with the requirements of the Care Home Regulations and NMS. At the moment it is difficult to track and monitor what training each staff member has had and how this fits with the training profile of the whole staff team. In addition to this the manager should ensure that staff also receive more structured specialist training to assist them in communicating with people and in caring for more complex healthcare issues. The home has a core group of experienced staff, and health care and social services staff report that they listen to advice and provide good care to residents. 19 Beech Avenue DS0000022536.V366119.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is bringing in changes that will ensure that the home is being run in the best interests of the people living there, and that they are safe and well cared for. EVIDENCE: The manager trains and develops staff who are generally competent and knowledgeable to care for the residents. The service focuses on the individual, takes account of equality and diversity issues, and works in partnership with families or close friends, as appropriate, and professionals. The manager is a Person Centred Trainer for the organisation and is well underway in introducing a new style plan to her staff team. However the staffing situation currently makes this difficult to translate into practice by limiting peoples options and choices. 19 Beech Avenue DS0000022536.V366119.R01.S.doc Version 5.2 Page 23 The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area in developing ways of whole systems checking to ensure quality of the service. This is also required in the area of gaining feedback from people who have contact with the home, relatives, professionals and in developing the use of advocates. For example a quality assurance system would help to identify gaps noted on inspection in fire training. As not all staff had received up-to-date training a requirement is made to ensure this happens especially as all staff at some point sleep over in the house, and are in charge in the event of a fire. There is currently not always a qualified first aider for each shift. The manager needs to carry out an assessment to determine if this is necessary or not and make this assessment available to CSCI. Guidance can be found on CSCI professional website on how to carry out an assessment. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. The evidence to support the comments made is satisfactory, although there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it is planning to improve. 19 Beech Avenue DS0000022536.V366119.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 x 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 4 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 3 17 32 33 34 35 36 3 2 3 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 2 x x 2 x 19 Beech Avenue DS0000022536.V366119.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. 1 Standard YA42 Regulation 23 Timescale for action All staff must receive fire training 30/08/08 and instructions on a regular basis to keep people safe Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations Each person should be assessed by a multi-disciplinary team to determine capacity to make decisions under guidance from Mental Capacity Act 2005, and if appropriate an advocate found to represent people. The homes high reliance on agency staff should be reviewed in order to give people living at the home a better service The manager should produce a training and development programme that will ensure staff receive suitable levels of training in line with the requirements of the Care Home Regulations and NMS and to meet service users needs. The manager should undertake an assessment to determine the level of qualified first aiders required in the home, as described in the CSCI Guidance Logs. DS0000022536.V366119.R01.S.doc Version 5.2 Page 26 2. YA33 3. YA35 4. YA42 19 Beech Avenue Commission for Social Care Inspection CSCI Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 19 Beech Avenue DS0000022536.V366119.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!