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Inspection on 22/02/06 for 44 Manorford Avenue

Also see our care home review for 44 Manorford Avenue for more information

This inspection was carried out on 22nd February 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

44 Manorford Avenue is a real home to the 2 residents that live there. They are fully involved in any decisions made and assist with all daily living tasks. There have been no admissions or discharges for over 3 years and both the management and small staff group are stable.

What has improved since the last inspection?

Of the 6 outstanding requirements 1 has been fully met and work is being planned to make further improvements, including the fitting of a new kitchen. The manager has continued to review and refine information to ensure the residents understand it.

What the care home could do better:

The main outstanding requirement is to improve the garden area including making safe the garage door and window, which has been poorly repaired and update the kitchen facilities.

CARE HOME ADULTS 18-65 44 Manorford Avenue West Bromwich West Midlands B71 3QH Lead Inspector Mike Kirton Unannounced Inspection 22nd February 2006 10:00 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 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 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 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. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 44 Manorford Avenue Address West Bromwich West Midlands B71 3QH 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) 0121 532 2749 Optimum Care Services Tracy Rayers Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 19th September 2005 Brief Description of the Service: 44 Manorford Avenue is a small residential home, registered to care for three people with a learning disability between the age of 18 and 65. The detached four-bedroom property is situated at the end of a crescent within a residential area close to bus routes into West Bromwich town centre. At the front of the home there is a small garden and parking space, to the side and rear are extensive gardens. The ground floor consists of front porch, hallway, lounge, dinning room, kitchen, laundry, and shower and toilet. Upstairs are the four bedrooms (including staff), toilet and bathroom. Care is provided on the basis that it is the service users home and they are involved in all decisions that are made. The size of the home enables staff to provide a high level of support and interaction with each service user to promote independence. Frequent use is made of outside agencies including day centres and advocacy services. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 hours and included a tour of the buildings, interviews with the manager and informal discussions with residents and staff on duty. Health and safety records were also examined. What the service does well: 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. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 6 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 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 19th September 2005. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 19th September 2005. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 19th September 2005. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The home maintains an excellent level of support and assistance to ensure resident’s needs are met. There is good access to specialist services and independence is always promoted. EVIDENCE: All residents’ preferences have been assessed and accurately recorded in their care plans. This included daily routines and personal choices. During this and previous inspections they are seen to be fully involved in the running of their home and are encouraged by the staff team to express their views. They can get up and go to bed when they like, have meals and drinks at times to suit them, and dress how they wish. Health care needs are also fully assessed and documented along with all appointments to specialist medical professionals. The local health centre now provides a full annual body health check. The medication records were examined and had been completed accurately. Copies are kept of prescriptions and a receipt and return book is maintained. A medication review has recently taken place, again a service provided by the health centre. Training is still required for staff responsible for administration (see requirement 3 standard 34). 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has an excellent complaints procedure available in appropriate formats. Their adult protection procedures are sufficient to ensure the risk of any abuse is kept to a minimum and action to protect their safety would be implemented immediately. EVIDENCE: The homes complaints procedure contains all the information required including contact information for the Commission. This is available on audiocassette and given to each resident. The written copy contained within the visitors book, is easy to read and enhanced by the use of appropriate pictures. There is also a booklet called ‘Listen to Me’ which is designed to encourage feedback. The home has there own adult protection and whistle blowing policy and local social services procedures. The manager was questioned and responded appropriately about what she would do should any allegation of abuse be made. Action taken would ensure the health and safety of residents is protected. Although no recent training has been provided the issues are covered in the NVQ qualifications, which all staff are undertaking. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 Manorford Avenue is a small home with a friendly and relaxed atmosphere. Action is required to modernise the facilities and undertake the outstanding repairs. EVIDENCE: The home was found to be clean and tidy throughout and the main living areas i.e. lounge and dining room, decorated and furnished to a good standard. Essential repair work has not yet been carried out to the garden and garages however this should be completed by May 2006. New locks have been fitted to the patio door and new flooring laid in the upstairs bathroom. Laundry facilities are appropriate for the number of residents and their needs. All chemical are stored appropriately and the required risk assessments are completed. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not fully assessed on this occasion but were monitored against outstanding requirements. For further information please refer to the previous report dated 19th September 2005. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The manager has the necessary skills and experience to manage the home. An appropriate quality assurance system is in place for the size of the home and health and safety checks and records are well maintained. EVIDENCE: Tracey Rayers has worked for Optimum Care Services for 13 years and been the manager at Manorford Avenue for 3 years, registered with the Commission on 1st August 2002. Although she has undertaken regular training appropriate to her position she has yet to completed the NVQ 4 in management qualification. The home has their own quality assurance system based upon scores given to them by the Commission for each standard assessed. This has shown an improvement over the years. They also undertake a monthly review of furniture and fittings and completed comment cards are kept in residents care records. Advocacy services also visit the home on a regular basis and check that residents are happy with the service they receive. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 15 Records required to ensure the health and safety of staff and service users were inspected. Fridge, freezer, water, and cooked meat temperatures were recorded. The homes gas landlords certificate, 5-year electrical wiring test was in date and portable electrical equipment was tested. Risk assessments on the building and staff/service users activities is completed and reviewed every 12 months and public liability insurance was in place. A fire risk assessment and evacuation plan is in place, and all equipment is regularly serviced and tested as required. Fire evacuation drills are carried out and a fire marshal is identified for each shift. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 16 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 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 2 X 3 X X 3 X 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 17 Yes 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 YA24 Regulation 16,23 Requirement The kitchen cupboards had several doors missing, were looking dated and need replacing. The garage side door and window that is no longer used needs boarding up securely. These are outstanding requirements from the l27th January 2005. 2. YA34 18 Staff should have a statement of terms and conditions and are subject to a 3-month probationary period. These are outstanding requirements from the l27th January 2005. 3. YA35 18,19 The gaps identified in the individual staffs training programme must be met particularly in relation to the administration of medication. These are outstanding requirements from the l27th January 2005. 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 18 Timescale for action 01/05/06 01/05/06 01/05/06 4. YA36 18,19 All staff should receive an annual appraisal. These are outstanding requirements from the l27th January 2005. 01/05/06 5. YA37 9 The manager should be qualified to level 4 NVQ in management and care. These are outstanding requirements from the l27th January 2005. 01/05/06 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 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 44 Manorford Avenue DS0000004785.V284043.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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