Inspection on 17/08/07 for 64-70 Holbrook Avenue

This inspection was carried out on 17th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Holbrook Avenue, 64-70 Holbrook Rugby Warwickshire CV21 2QQ Lead Inspector Justine Poulton Unannounced Inspection 17th August 2007 13:30 Holbrook Avenue, 64-70 DS0000068552.V335227.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 Holbrook Avenue, 64-70 DS0000068552.V335227.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. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holbrook Avenue, 64-70 Address Holbrook Rugby Warwickshire CV21 2QQ 01788 577239 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) Coventry and Warwickshire Partnership Trust Caroline Joanna Pritchard Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care and accommodation to 4 service users under 65 for reasons of learning disability. N/A Date of last inspection Brief Description of the Service: 64-70 Holbrook Avenue is a purpose built bungalow close to the town centre of Rugby. It provides a service for up to four adults with learning disabilities. The home has recently reregistered under Coventry and Warwickshire Partnership Trust and is staffed 24 hours a day. The property is leased from Leicester Housing Association. The home has a large garden, parking and level access. There are four single bedrooms each with toilet facilities en suite and doors onto a small patio area and the garden. The house also has a small lounge, dining room, kitchen and laundry. The office and staff sleeping-in accommodation is combined. Two parks and Rugby town centre are within walking distance. Information regarding funding was not available for this inspection. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection of this service following reregistration with Coventry and Warwickshire Partnership Trust. The inspection was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. Identified key standards were looked at. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff and the team leader were spoken with. It was not possible to speak with the people who live in the home as they have no verbal communication. One completed service users survey was received which had been completed with support from a family member. Also one completed relatives survey was received. Two people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. Records, policies and procedures were examined and the environment was looked at. All of the people who live in the home were in for all or part of the inspection. The inspector would like to thank the service users, team leader and staff for their hospitality and co-operation during the inspection. What the service does well: The home continues to meet the key national minimum standards ensuring positive outcomes for the people who live there. The home had a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples needs and wants were met. Risk assessments enable people to take meaningful risks in a safe manner, and the behaviour plans looked at were of an extremely high quality, and appeared effective. People are supported to make decisions about their lives on a daily basis by staff who work to ensure that they are able to recognise and interpret peoples limited verbal and non verbal communication skills. People are offered opportunities to participate in activities and leisure pursuits that make use of the local and wider communities, as well as in house. The involvement of families and friends is important to people, and is encouraged by the home. A clean, tidy and well stocked domestic kitchen enables people to choose from a range of meal options. Individual personal care needs are met sensitively and discreetly by staff in line with peoples assessed needs. Their health and wellbeing is also promoted Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 6 via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on their behalf. The home has both a complaints policy and an adult protection policy in place. Staff were aware of how people with no verbal communication make their needs known. At the time of this inspection we had received no complaints about the home. Staff were aware of their responsibilities regarding adult abuse, and were undertaking training provided by the Warwickshire Vulnerable Adult Committee. The home presented as comfortable and clean. It was decorated nicely with modern furniture and soft furnishings throughout. Staff numbers were satisfactory on the day of the inspection. The manager is supported by a competent team leader with whom both the residents and staff team appeared to have a good rapport. Health and safety is managed effectively within the home. 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. Holbrook Avenue, 64-70 DS0000068552.V335227.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 Holbrook Avenue, 64-70 DS0000068552.V335227.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): 1 Quality in this outcome area is good. Suitable and appropriate information to help prospective residents (and their representatives) to decide if the home is the kind of place they would like to live in is available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is the first inspection of this service following registration with us under Coventry and Warwickshire Partnership Trust. The home was previously registered for a considerable number of years however, with a stable resident group, who continue to live there. The homes Statement of Purpose was looked at as part of the inspection. This document identified the types and levels of service that could be offered to specific user groups, however it required reviewing and updating to reflect the new service provider and Commission for Social Care Inspection details. As there have been no new service users admitted recently key standard 2 relating to the pre assessment process was not examined as part of this inspection. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 9 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, 9 Quality in this outcome area is excellent. People’s needs are well documented and reviewed so that staff are able to provide them with the support they require, in the manner they prefer it. Risk assessments that support people to live full lives in a safe manner are also in place. This judgement has been made using available evidence including a visit to the service. EVIDENCE: As part of this inspection two people were chosen for case tracking purposes. All of their care planning, health, medication, daily diaries and day service documentation was looked at. Both care plans followed a similar format, which included an essential lifestyle plan, and need to know file as well as a medication file. They were written in the first person, thus ensuring that they were person centred and provided a sense of ownership for the people using the service. The required levels of Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 10 support were detailed, which enabled staff to provide appropriate care and assistance for each person. Information available indicated that peoples care plans are reviewed routinely on a regular basis. Records seen also evidenced that risk assessment is good and ensures that staff have specific guidelines to follow to minimise risk, and guidance in the event of needs changing. Again these were reviewed in line with the care plans. In addition to their risk assessments, the two people chosen for case tracking had very comprehensive, detailed and specific behaviour plans in place, which are given to people visiting the service to read, in order that they be aware of the behaviours that may be displayed and the strategies that are used to manage them. These have been drawn up with guidance by a behavioural therapist, and were seen to be used consistently throughout the team. All four people that live in the home have no verbal communication skills, however it was apparent throughout the inspection the staff were able to interpret their individual means of communication, and were seen to support them with making decisions about their day to day lives. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 11 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, 17 Quality in this outcome area is good. People are offered a variety of age, peer and culturally appropriate activities that make best use of in house and community facilities. Relationships with families and friends are promoted. A healthy, nutritious diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Unlike other homes within the trust, Holbrook Avenue does not employ separate day services staff to provide an activities service to the people living there. Instead, the care staff are employed to cover the home on a 24 hour basis, and support people with activities during the daytime. Staff spoken with said that activities are planned on a monthly basis at house meetings, taking into account individual preferences, and then put into a Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 12 weekly plan for each person. The team leader said that she is introducing a more structured goals based day service programme that is more in line with the day services that are provided in other homes run by the trust. The monthly plan includes pictures of the planned activities. It was advised that these are in the process of being enlarged so that each person can have a picture of their planned activities for the day and also a photo of the staff member that will be supporting them with it, to help with introducing a more structured approach. Activities planned for the week commencing 13th August included a visit to the sea life centre, horse riding, art and crafts, garden games, dinner out and personal shopping. Activity records and the daily diaries of the two people being cased tracked confirmed that very few of these activities actually took place however. The reason for this was recorded on the rear of the activity sheet, along with any alternatives offered. Reasons included a lack of money, and a shortage of staff. A house news letter that has been introduced to celebrate the homes activities and achievements included information about theme days that had been held such as St Patrick’s day, American Independence day and an ‘African’ day. The team leader said that the African day was held to help staff understand more about and celebrate one persons cultural background. During the inspection all of the people living at the home went out for one reason or another, including to go to the local shop to buy the ingredients to make some cakes, which were made upon return to the home. As previously recorded, the people resident in the home have no verbal communication. Staff are therefore relied on to assist and support with maintaining personal relationships with relatives and friends. These relationships are seen as being of prime importance by the home, and are facilitated as appropriate. The home has a domestic kitchen which was clean and tidy on the day of the inspection. It was noted that it is kept locked when not in use however, when it was in use there appeared to be no restriction on people accessing it. It was well stocked with plenty of fresh produce available as well as frozen and tinned foods. Menus are planned on a weekly basis around what staff know the people living in the home like to eat, whilst ensuring a healthy well balanced diet. Staff spoken with said that people are encouraged to get involved in the preparation of their meals through being in the kitchen to observe, smell and taste. This was seen during the inspection with lunch preparation and making cakes later in the afternoon. The necessary food hygiene and safety records and checks were in place. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. People who live in the home receive personal support in line with their assessed needs. Their healthcare needs are monitored and addressed. Medication is managed safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has their levels of personal care and support detailed clearly within their care plans. This ensures that staff are able to provide the necessary levels of assistance as directed by their assessed needs. During the inspection staff were seen to assist people with their personal care needs sensitively and discreetly. Information available within the personal files looked at confirmed that people are supported with their healthcare appointments such as the dentist and optician at the recommended intervals. Records indicate that people have also had an annual health check with their surgery practice nurse. Other specialist Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 14 healthcare professionals involved with people living in the home are detailed within the care plans looked at, and include the community nurses, consultant psychiatrist and behavioural therapist. None of the people living in the home currently administer their own medication. Instead they rely on the staff team to undertake this for them. Medication is provided by a local pharmacy in blister packs, accompanied by medication administration record charts (MAR). The medication records for the two people being followed for case tracking purposes were checked and found to be correctly completed. It was noted that each person had a medical consent to treatment, which included medication administration, in relation to their capacity to consent, signed by their Consultant Psychiatrist. Necessary protocols for medication administration such as rectal diazepam or other as required medications were also in place and signed by the Consultant Psychiatrist. Procedures for checking medication into the home, stock checks, change tracking sheets and medication counts appeared robust. Staff spoken with said that they are not allowed to administer medication to people until they have completed training, and then they undergo annual competency checks with a qualified nurse from the trust. It was noted that any medication errors were recorded, and incident sheets had been completed correctly, however it was extremely difficult to cross reference the incident code on the MAR chart with the completed incident form as no details of the error or reference number of the incident form were recorded on the back of the chart. This was discussed with the team leader who undertook to ensure that this will be actioned in the event of any future medication incidents. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 15 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, 23 Quality in this area is good. The homes policies for complaints and protection from abuse ensure that people’s views are listened to and acted upon, and that they are safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a service user friendly version of the organisations complaints procedure which is available to the people who live in the home should they need it. As recorded previously in this report, the people who live in this home have no verbal communication. One completed survey received makes no comment about whether the person knows how to complain or who to speak to. No reason for this was given. The survey received from a relative clearly indicates that they are aware of how to make a complaint. It was apparent from watching the staff interact with the people living in the home that they were able to interpret the non verbal clues that people were giving to indicate that they were unhappy with something, and respond appropriately. Similarly, peoples behaviours are seen very much as a means of communication and were responded to accordingly. The team leader was unable to locate the homes complaints log, but assured that none had been received since the last inspection. Similarly, we have received no complaints. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 16 The home also has a policy and procedure in place for the protection of vulnerable adults from abuse. Staff were currently undertaking training in this area via vulnerable adult workbooks provided by Warwickshire Vulnerable Adults Committee. Once completed these workbooks get returned to the committee for verification. Staff spoken with were knowledgeable about the different forms of abuse and were able to say what they would do should abuse be suspected or disclosed. Clear audit trails and financial management guidelines were in place for individual personal spending monies. Each person’s money is checked on a daily basis, and two members of staff are required to sign for each transaction undertaken. Monies checked during the inspection tallied with balances recorded and receipts available. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this outcome area is good. The appearance of this home creates a pleasant, comfortable and homely environment that is well maintained. The home presents as clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a purpose built bungalow set in a residential area of Rugby. It consists of four single bedrooms each with toilet facilities en suite and doors onto a small individual patio area and the garden. The house also has a small lounge, dining room, kitchen and laundry. The home has a large garden, parking and level access. Staff said that the communal areas of the home had recently been decorated, and were painted in a bright sunny colour. They were clean and fresh with evidence of good odour control. The furniture in the Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 18 communal areas was nice and the areas were personalised with pictures that the people living in the home had done. Individual bedrooms were seen to be very different and reflective of peoples personalities, tastes and tolerances. One bedroom in particular was very sparse and in need of decoration, however the team leader was able to explain the reasons for this and assured that all of the necessary work to make the décor of the room nice for its occupant was in process. The home has a separate utility room that is set away from the kitchen. Personal protective clothing was available for staff to use. On the day of the inspection the home was clean and tidy. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is adequate. Recent recruitment will ensure that people who live in this home benefit from sufficient numbers of staff. Recruitment practices ensure that they are safeguarded from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs 15 permanent staff including the manager. The team leader advised that the home has been experiencing staffing problems recently as there are three vacancies, one staff member on maternity leave and one staff member currently on suspension without prejudice, and has had to rely on agency workers to ensure satisfactory staffing levels are maintained. It was advised that the agency workers used generally know the people who live in the home well, as they have covered a number of shifts. She was pleased to report however that a recent recruitment drive had been successful in securing staff to the three vacancies, pending all of the necessary pre employment checks. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 20 Three staff files were looked at to ascertain whether recruitment practices were robust and safeguarded the people living in the home. Their files contained all of the necessary documentation including a criminal record check and two written references. This confirmed that a thorough recruitment process that protects the people living in the home is undertaken. Training records provided by the home indicate that a number of staff require refresher training and updates in the mandatory areas of fire safety, manual handling, basic food hygiene. Other more specific areas of training provided for staff include the administration of medication, basic infection control, rectal diazepam and vulnerable adults. Staff are also registered on the Learning Disability Awards Framework induction and foundation programmes. Information provided in the pre inspection questionnaire received prior to the inspection confirms that six staff have completed their NVQ II or above. It was noted from the training information provided, that apart form the PAMOVA physical intervention training that staff receive, there is no other training in respect or behaviours that challenge. A recommendation to this effect is therefore made. The team leader said that it was proving difficult to access training for the staff provided by the trust as the information is sent out on line, and the service does not have an internet connection. Any training information received via the post is usually fully booked as services that have received it electronically have taken the places. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 21 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, 42 Quality in this outcome area is good. The management systems in place at the home ensures that the people that live there benefit from a well run service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager for the service was not available at the home on the day of the inspection. The team leader on duty advised that she was there on a temporary basis from another of the trusts services as the post was vacant, and being recruited to shortly. The team leader said that she had successfully completed her NVQ III. Throughout the inspection she appeared confident and extremely competent in Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 22 her role, was able to answer all questions put to her about the home, and knew the care and support needs of the people living in the home. Staff on duty appeared comfortable with her, and positive open relationships were observed. The team leader said that quality audit questionnaires have been sent out to relatives, staff and other professionals who have links with the home, and were in the process of being returned. Once these had been received the information would be collated and a report generated from the responses provided. An action plan based on this report would then be generated. As with another service within the trust, it was advised that the people living in the home had not been given questionnaires as their communication abilities made it difficult to ascertain meaningful answers about the quality of the service they receive. Again however, throughout the inspection they responded to questions asked, by various means that included smiling and nodding and gestures. It is therefore recommended that the provision of easy, accessible surveys based around their individual methods of communication be looked into. In addition the quality of the service provided is monitored via monthly provider visits as required by regulation 26 and a monthly quality monitoring checklist that the team leader completes. Peer audits, which are undertaken by other managers from the organisation, also take place regularly. Regular staff and house meetings are also held. Information provided in the pre inspection questionnaire indicates that health and safety measures are robust and are undertaken at the required intervals thus maintaining the health and safety of all who live in, work or visit the home. A sample of these were looked at during the inspection and confirmed this. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 23 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 4 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 24 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 YA12 Regulation Requirement Timescale for action 14/10/07 2 YA35 16(2)(m)(n) The registered person must ensure that sufficient resources are available to allow people to participate in planned activities. 18(c)(1) The registered person must 30/11/07 ensure that all staff have undertaken mandatory training within the required intervals. 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 2 3 Refer to Standard YA35 YA35 YA39 Good Practice Recommendations It is strongly recommended that the trust provide training in behaviours that challenge for all staff. It is recommended that how the home receives information about staff training be looked into. It is recommended that quality surveys based around the service users individual methods of communication be looked into. Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Holbrook Avenue, 64-70 DS0000068552.V335227.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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