Inspection on 19/04/04 for 27 Graham Avenue

Care Homes For Adults (18 ­ 65)27 Graham AvenueBrighton East Sussex BN1 8HAUnannounced Inspection19th April 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 27 Graham Avenue Address 27 Graham Avenue, Brighton, East Sussex, BN1 8HA Email address admin@rogate.org Name of registered provider(s)/company (if applicable) Hallcreed Limited Name of registered manager (if applicable) Ms Kathleen Penney Type of registration Care Home No. of places registered (if applicable) 4 Tel No: 01273 552626 Fax No: 01273 552626Category(ies) of registration, with (number of places) Learning disability (4) Registration number H100000063 Date first registeredDate of latest registration certificate 30th July 2002Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionYES NO 4/11/03 If Yes refer to Part C27 Graham AvenuePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 319th April 2004 4.00PM Jenny BlackwellID Code102922Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection27 Graham AvenuePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement27 Graham AvenuePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 27 Graham Avenue. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.27 Graham AvenuePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The home is registered to accommodate up to 4 people with learning disabilities. The home is set in a residential area in Brighton close to local parks shops and pubs. The road has regular bus service and is close to Preston Park train station. The home is a three-story semi-detached building, with a patio area and long rear garden. The home resembles a family home with appropriately sized rooms for the service users needs. The home is one of four homes run by Hallcreed Ltd27 Graham AvenuePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection for the home and the inspector was able to meet with the staff. The manager came to the home to provide the inspector with some information. The inspector spent time with the service users individually and as a group. The inspector followed up on requirements and recommendations made from the previous inspection. The manager has been working towards meeting the requirements and recommendation and has met all within the timescales given. The service users responded positively during the inspection and appeared comfortable and relaxed with the staff. Choice of Home (Standards 1 ­ 5 ) 4 of the 5 standards assessed were met. The homes statement of purpose sets out the homes aims of supporting people with learning disabilities within a community setting The service users guide has been put together using widget symbols to help the service users understand the guide. The home does not intend to admit any new service users for the foreseeable future. On the day of the inspection the service users records were not available for inspection. The files had been taken to the main home for adjustments to be made by the administrator. Individual Needs and Choices (Standards 6 ­ 10) 2 of the 5 standards assessed were met. The inspector has viewed the care plans for each service user on a previous inspection. On this inspection the service users records and care plans were not in the home. One persons plan could not be found. Requirements and recommendation were made about record keeping. The home has developed pictorial information to help service users make decision outside and inside the home such as meal choices and activities. The staff believe that the service users contribute on a basic level to the daily running of the home, by asserting their likes and dislikes. Lifestyle (Standards 11 ­ 17) 7 of the 7 standards assessed were met. The staff encourage service users to be independent as possible and support the service users to participate in household tasks. Each service user attends day services, the service users socialise in their local community, and they go to their local pub and cinemas. This year the home has arranged two holidays with the service users one in the summer and the other later in the year. The home has a relaxed homely atmosphere where staff were seen to interact well with the service users. The service users spoken to liked the food provided at the home.27 Graham AvenuePage 6 Personal and Healthcare Support (Standards 18 ­ 21) 1 of the 1 standard assessed were met. The staff are sensitive supporting service users with personal care, and support people in private. All service users have access to G.Ps and community health services. Concerns, Complaints and Protection (Standards 22 ­ 23) 1 of the 1 standards assessed were met. The home has guidance on physical restraint and good recording systems. The home operates an appropriate financial system when dealing with the service users finance. Environment (Standards 24 ­ 30) 2 of the 3 standards assessed were met. The home is maintained well with good decoration. The gardens are well kept and the service users make use of the patio area. The home has a ceiling hoist for transferring a service user to her en suite bathroom. The home was clean and tidy on the day of the inspection. The care staff do the cleaning and cooking in the home. It was required that a service users window was cleaned or decorated to remove mould. It was also required the home install telephone facilities in the sleep-in room for staff access during the night. Staffing (Standards 31 ­ 36) 1 of the 1 standards assessed were met. The staff team has been increased to 4 since the last inspection. Two staff members of staff are now on each shift and one sleep-in during the night. Conduct and Management of the home (Standards 37 ­ 43) 0 of the 0 standards assessed were met. None of the standards in this section were assessed during this inspection. The inspector would like to thank the service users and staff for their help during the inspection.27 Graham AvenuePage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)27 Graham AvenuePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 17(1)(a) sch 3 23(2)(d) YA6 It is required that care plans or summaries of information such as risk assessments are held in the home at all times. It is required that the home cleans or decorates the service users window to remove the mould. It is required the home install telephone facilities in the sleep-in room for staff access during the night. Immediate2YA2430/5/04316(2)(a)(i)YA2430/5/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 YA6 It is recommended that the care plans are reviewed every six months.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report 27 Graham Avenue Page 9 Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)YES NO NO YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES NO YES 4 0 0 NO NO YES YES 3 0 19/04/04 4.00PM 4.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 27 Graham Avenue Page 10 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met(Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.27 Graham AvenuePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The home has a statement of purpose in place that meets the standard. The home has made adjustments to the original to reflect the specific service within the home. The service users guide has been well put together using widget symbols to help the service users understand the guide.Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? All four service users moved to the home many years ago and have original assessments undertaken by care managers. The home does not intend to admit any new service users for the foreseeable future.27 Graham AvenuePage 12 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The homes statement of purpose sets out the homes aims of supporting people with learning disabilities within a community setting. The staff interviewed had a sensitive approach when supporting and enabling the service users to communicate.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The home has a comprehensive trial visit policy with a minimum of 3 months. The current service users have lived in the home for many years, if in the future new service user were to move into the home a structure admission procedure, including visits to the home, would take place.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 1 Key findings/Evidence Standard met? On the day of the inspection the service users records were not available for inspection. The files had been taken to the main home for adjustments to be made by the administrator. See standard 6.27 Graham AvenuePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 1 Key findings/Evidence Standard met? The inspector has viewed the care plans for each service user on a previous inspection. However on this inspection the service users records and care plans were not in the home, the manager had taken them to the main home of the organisation, for information to be entered by the organisations administrator. The service manager bought some information to the home during the inspection and the manager came to the home to provide the inspector with verbal information. The care staff confirmed that the records were usually in the home. One persons plan could not be found. In addition it was unclear if the care plans are reviewed every six months. It is required that care plans or summaries of information such as risk assessments are held in the home at all times. It is also recommended that the plans are reviewed every six months. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The staff were seen to respond sensitively to a service user when helping her reduce her caffeine intake. The home has developed pictorial information to help service users make decision outside and inside the home such as meal choices and activities. The current service users use limited verbal communication using other methods of communication to assert their choices. The staff were seen to respond to these choices during the inspection.27 Graham AvenuePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Since the previous inspection the manager has endeavoured to gain feedback from the service users about living in the home. A pictorial chart was developed to gain the person emotional response to activities. This chart was displayed in a prominent position during this inspection. The staff believe that the service users contribute on a basic level to the daily running of the home, by asserting their likes and dislikes.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? The service manager bought from the main home the service users updated risk assessment to the home during the inspection. The home has including basic risk assessments for each service users on window restrictors and radiators. The home has identified a risk to one service user with the windows and is placing restrictors to the window. The home identified a risk to another service from the radiator in her bedroom and has fixed a thermostat. (Recommendation made see standard 6) Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 2 Key findings/Evidence Standard met? During the inspection the manager and inspector discussed the storage and accessibility of the service users information. Generally the home stores some records at the home and the other records are at the main home of the organisation. Some records could not be found during the inspection. (see requirement standard 6)27 Graham AvenuePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? The staff encourage service users to be independent as possible and support the service users to participate in household tasks.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Each service user attends day services, the inspector was shown the activities programmes from the day centres. The staff do not believe the current service user group would benefit from exploring employment opportunities.27 Graham AvenuePage 16 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The service users socialise in their local community, the go to their local pub and cinemas. The service users have their own car at the home but also use the bus service to travel around Brighton. The staff and service users plan trips out most weekends.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? This year the homes has arranged two holidays with the service users one in the summer and the other later in the year. The inspector spoke with the service users who indicated they were looking forward to their holidays. The staff demonstrated knowledge of each persons likes and interest. They supported them to participate in a range of activities.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home supports relationships between the service users and their family and friends. Each person has the opportunity to meet with his or her family or friends in private in the home. One service user talked to the inspector about her visits to and from her family.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home has a relaxed homely atmosphere and staff interact well with the service users. The home has looked at increasing the opportunity for privacy for the service users by providing looks on their bedroom doors. However it has been agreed by the home for the time being that this is not feasible for the current service users. This is recorded in their care plans.27 Graham AvenuePage 17 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home had a nutritious meal planner. Service users are encouraged to choose meals although they are not always interested in participating. The service users spoken to liked the food provided at the home. The inspector was able to be with the service users during the their evening meal, where the staff and service users ate together and chatted.27 Graham AvenuePage 18 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The staff are sensitive supporting service users with personal care, and support people in private. Currently the staff team are all female this does not appear to cause difficulty with the male service users. One service user had a ceiling hoist installed to help her use her ensuite bathroom.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed. Standard met? XX 027 Graham AvenuePage 19 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed.27 Graham AvenuePage 20 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed. X X X X X X X Standard met? 027 Graham AvenuePage 21 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home has guidance on physical restraint and good recording systems. The home operates an appropriate financial system when dealing with the service users finance.27 Graham AvenuePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is maintained well with good decoration. The home is set in a residential area and is in keeping with its surroundings. The furnishings are appropriate for the service users. The home has recently bought new settee and armchairs. The gardens are well kept and the service users make use of the patio area. One service users metal windows had mould growth it is required that the home clean or decorate the windows to remove the mould. Also it is required the home install telephone facilities in the sleep-in room for staff access during the night.27 Graham AvenuePage 23 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not assessed. YES NO NO X X X X Standard met? 0 X XX X X X27 Graham AvenuePage 24 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? This standard was not assessed.27 Graham AvenuePage 25 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home has a ceiling hoist for transferring a service user to her en suite bathroom. The home is restricted to providing accommodation for service users who are mobile, as the home does not have a lift or wide doorways to accommodate permanent wheelchair users.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean and tidy on the day of the inspection. The care staff do the cleaning and cooking in the home. The service users are encouraged to participated in the cleaning of the home and some of those spoken to indicate they enjoy cleaning and tidying. The laundry facilities are managed appropriately to meet the standard.27 Graham AvenuePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessedStandard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? The standard was partly assessed. The staff on duty skills were assessed and were seen to have knowledge of each service users needs and issues about learning disabilities. The training plans will be examined with the manager on the announced inspection.27 Graham AvenuePage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 0 4 0 177 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 0 177 0 177 Nursing 0 0 0003 Key findings/Evidence Standard met? The staff team has been increased to 4 since the last inspection. Two staff members of staff are now on each shift and one sleep-in during the night.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.27 Graham AvenuePage 28 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? This standard was not assessed.027 Graham AvenuePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This standard was not assessed. X 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed.27 Graham AvenuePage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? This standard was not assessed.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed.27 Graham AvenuePage 31 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? This standard was not assessed.27 Graham AvenuePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulatory Inspector Second Inspector Regulation Manager DateSignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.27 Graham AvenuePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 19th April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: 27 Graham Avenue Page 34 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportNONOProvider comments are available on file at the Area Office but have not NO been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NO27 Graham AvenuePage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.27 Graham AvenuePage 36 - 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. 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