Inspection on 11/04/05 for Avenue Road

This inspection was carried out on 11th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Avenue Road 27/09/05

Avenue Road 27/10/04

Avenue Road 01/06/04

Avenue Road 15/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 35 Avenue Road Darlaston Walsall West Midlands. WS10 8AR Lead Inspector Lesley Webb Unannounced 11& 13 April 2005 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 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 Stationary 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. 35 Avenue Road Version 1.10 Page 3 SERVICE INFORMATION Name of service Avenue Road Address 35 Avenue Road Darlaston Walsall West Midlands. WS10 8AR 0121 526 3313 0121 526 3313 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Swan Village Care Services Ltd. Ms Sarah Perry Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 35 Avenue Road Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 27TH October 2004 Brief Description of the Service: Avenue Road is a detached two-storey premise that is connected to all main services. The home offers five single bedrooms (without en-suite facilities), a large lounge and separate dining room. There are bathing, shower and toilet facilities on each floor. The home is owned by Swan Village Care Services Limited, who also own several other care homes in the West Midlands and a Day Centre.The home is situated in a quiet area of Darlaston and is close to all the local amenities such as shops, pubs, library, parks and public transport. The home is registered for the care of five adults with a learning disability. All of the present service users also demonstrate challenging behaviour.Staff at the home uses a client-focused approach, with the aim being to encourage and develop maximum potential and independence for each service user. All care packages incorporate choice, privacy, dignity and respect. 35 Avenue Road Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived at the home at 1.40pm and stayed until 9.40pm and again visited two days later arriving at 5.30pm and left at 7.30pm. During both visits the inspector met three of the four service users living at the home and six members of staff, all of which were either spoken to or interviewed. In addition to this records were viewed and practices observed. The last inspection took place in October 2004 and since then the Acting Manager, Ms Sarah Perry has completed her registration process and is now the Registered Manager of Avenue Road. The inspector would like to thank service users and staff for their assistance and co-operation during both days spent at the home where she was made to feel very welcome. What the service does well: What has improved since the last inspection? Since the last inspection many staff have undertaken lots of courses that help them to care for everyone living at the home, with only Infection Control remaining outstanding for everyone. 35 Avenue Road Version 1.10 Page 6 The manager has been in post for about one year and in that time the inspector has found an improvement in staff morale. Staff who were spoken to said, “She listens to our views and ideas” and “interacts with service users”. These views were reinforced by comments from service users and checking records that showed an increase in meetings and supervision. The manager has also obtained service users and their family’s views of the home in the form of surveys and questionnaires, which she is going to examine in detail before making a report of the findings. It was also pleasing to find that staff recruitment and selection records were now in place as previously these had not met legal requirements and did not ensure service users were protected. What they could do better: Every service user file examined by the inspector had missing health related information. Health care monitoring and recording is poor and must be improved quickly to ensure that people living at the home get the individual care they need in a timely fashion. The home must improve medication recording and complete assessments that decide how much support service users need to manage their own medicines. Staff interviewed did not give good reasons why service users do not look after their own medication, with one opinion given that “they would not be trusted”. Also, when asked if they look after their own medication both service users who were interviewed confirmed that they did not, but could not give a reason why. When interviewed staff said that key worker meetings take place every month with individuals living at the home to make sure service users plans of care are up to date but records seen by the inspector did not support these comments. Also when service users were asked if they knew what was in their plans of care one replied “no” and another “I have looked at my file, I think some of it is good and some bad” but could not give any examples. Meetings must take place every month to review plans of care with the full involvement of the service user. A staff training and development programme must be put into place that demonstrates staff have the qualifications needed to meet the needs of service users. This must include maintaining certificates and completing an assessment that shows how staff training benefits service users. 35 Avenue Road Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 35 Avenue Road Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 35 Avenue Road Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2. The homes Statement of Purpose and Service User Guide give adequate information about services provided by the Home. Further development of the homes pre-admission assessment process must take place to ensure prospective service users aspirations and needs are fully assessed. EVIDENCE: An up to date Statement of Purpose along with other information about the home is displayed at the entrance to the home. The action plan submitted by the Home to address requirements identified in previous inspections stated that service users views of the home had been included in the Service User Guide, however the inspector could find no evidence of this on the day of inspection. Files sampled by the inspector contained Care Management Assessments completed by the purchasing authority and Independent Living and Social Skill Assessments completed by the home. All of the assessments completed by the home were done several years ago, as there have been no new 35 Avenue Road Version 1.10 Page 10 admittances to the home. The inspector advised the manager that for future assessments all of the areas of Standard 2.3 of the National Minimum Standards must be covered. 35 Avenue Road Version 1.10 Page 11 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 standard(s) 6, 7, 8 and 9. Care plans contained comprehensive information, aims and goals however further work is required by the home to ensure these are reviewed on a regular basis with the involvement of service users. staff respect service users right to made decisions, and that right is limited only through the risk assessment process. EVIDENCE: Three members of staff were interviewed and were able to give examples of aims/goals contained within service user care plans. These included hygiene, behaviour management and independence. The inspector verified these examples as accurate when checking the relevant care plans. Care plans also contained behaviour management guidelines again which staff demonstrated knowledge of, when being interviewed. When asked how service users are supported to be involved in the compilation and reviewing of their plans of care all staff stated that monthly key worker meetings occur with each service user where any changes are discussed, however when the inspector looked at the minutes of these meetings for two of the service users it was found that neither had been occurring on a monthly basis. The inspector interviewed two 35 Avenue Road Version 1.10 Page 12 service users both of whom said that they did not know what was in their care plans. Again both service users interviewed confirmed that they are able to make decisions about their lives with one stating, “I decide when I want to use the phone, what I eat and when I want to go out but I have to be in by a certain time”. When asked why the service user replied, “Because staff get worried about me and might have to call the police”. Staff confirmed that they attempt to involve service users in all aspects of home life in order that they can be involved in the decision making processes. Examples given included the compilation of shopping lists, household chores, holidays, what television programmes are watched and who they would like as key workers. Records from service user meetings verified these comments however the inspector recommended that these meetings occur more frequently has records indicated that only one had taken place this year. The inspector found an abundance of detailed risk assessments for all service users detailing assessments for a variety of areas including aggression, language, self injury, sexuality, mental health and vulnerability all of which had been reviewed and signed by the manager. When the inspector asked staff if service users are able to take risks all confirmed that they are and but where assessments had demonstrated risk levels to be high and potentially dangerous structures were put in place to attempt to minimise this. For example escorting to daycentres and service users using ‘walkie-talkies’ when out in the local community by themselves. It was also recognised by staff that if the risk was assessed at such a level that it could effect service user safety this could affect choice for example locks on kitchen cupboards due to incidents with knifes and a service user opening food products, taking bites then putting back. Service users that the inspector spoke to said that they did not mind locks on the kitchen cupboards as it stopped food “being messed with” and that “staff give us the keys if we want anything”. 35 Avenue Road Version 1.10 Page 13 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 standard(s) 12,13,15,16 and 17. Links with the community are good and support and enrich service users social and educational opportunities. Positive efforts are made to support service users to maintain family links. Recognition of individuals rights and responsiblities is apparent throughout the home. the meals in the home are good offering both choice and variety, catering for individual needs. EVIDENCE: Both service users confirmed that they take part in activities outside of the home giving examples including visiting Walsall, the pub and shopping. Both also expressed happiness that they maintained close contact with family members, visiting them on a weekly basis. One Service user said that they had recently suffered a family bereavement stating, “I get a bit down sometimes, but the staff talk to me, ask me if I’m alright or just listen to me”. The inspector also observed staff supporting a service user to make a telephone call to a family member in the privacy of their own bedroom. All staff interviewed confirmed that service users participate in activities with one member of stating, “each person does what they want, and they choose what 35 Avenue Road Version 1.10 Page 14 they want to participate in”. Records seen by the inspector confirmed that each person had an individual activity timetable and that activity evaluation sheets are completed. In addition to this activities are discussed in staff meetings, supervision and service user meetings. When assessing if service users rights are respected and responsibilities recognised the inspector asked a service user if he could do what he wants to living at the home. The service user stated, “No, you can’t bring alcohol in the house and you are not allowed to swear or hit each other”. When asked what would happen if you did any of these things the service user replied, “you would get into trouble and the police could be called”. These rules were confirmed within a document maintained on the service users file. The inspector asked both service users what they thought the food was like at the home and if they can choose when and what they eat. Both said that they are given choices, that staff ask them what they want on a daily basis and that they are asked if they would like to help choose meals for the weekly menu. When asking staff if they provide healthy choices of food all three staff interviewed stated that they attempt to ensure this occurs giving examples such as minimising fat contents and including vegetables and salad. All staff also confirmed that mealtimes are flexible with service users choosing to eat in the dining room or taking meals to their bedrooms if they prefer. The inspector found that weekly meal charts are maintained for each service user detailing what they have eaten (including meals outside of the home) along with menus that are used as a guide that are compiled with service user involvement. The inspector was also shown request forms, which service users complete if they want something ‘special’ to be added to the weekly shopping list. 35 Avenue Road Version 1.10 Page 15 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 standard(s) 19 and 20. Further work must be undertaken to ensure all service users health needs are assessed, monitored, recorded and met in full. Medication practices do not encourage independance, within a risk management framework. The systems for the recording of medication are poor and potentially place service users at risk. EVIDENCE: When asking service users how they are treated when they are ill one stated “staff keep an eye on me, ask me if I’m alright” and another stated “ alright, I’ve had an operation, my sister took me to the hospital and the staff made me a poster for my door saying I was brave”. Although staff demonstrated knowledge of service users medical needs records maintained by the home did not substantiate these and the inspector could find little evidence of the appropriate monitoring taking place. For example a service user had been to visit a General Practitioner in September 2004 where it was recorded that a referral to a Speech Therapist would be made however no appointment had taken place nor could the inspector find evidence that this situation was being looked into by the home apart from a comment made by a member of staff “I think the manager is looking into this”. Also records stated that a service user visited a General Practitioner in January 2002 where the 35 Avenue Road Version 1.10 Page 16 doctor advised the home to monitor the service users weight. A further doctors appointment in March 2005 states that the service user should be given smaller portions due to concerns regarding weight and mobility however when the inspector asked staff if advice had been sought from a Dietician they stated that this had not occurred. Three service users files contained weight charts but these were not being completed on a regular basis. The inspector found several all files sampled contained Initial Health Check forms however none had been finished in full and none had the Health Plan Checklists completed. Two service users were asked if they look after their own medication with both stating that they did not. When asked why this was again both did not know the reason. The inspector then asked the key workers of the two service users why they did not manage their own medication and both stated they were not sure but thought that either “they would not be trusted” or “they are not capable, they would not know how to”. Also both members of staff were not aware of a risk assessment being in place for the service users managing their own medication. When checking service users files the inspector confirmed that risk assessments were not in place for managing and administering medication. When checking the recording, storage and administration of medication the inspector found a tablet had been dispensed from its storage cassette but left in a medication tot, several signatures missing when medication had been administered and dates missing from the medication administration records resulting in confusion when attempting to complete audits. The inspector was pleased to find that all staff who administer medication have completed accredited medication training. 35 Avenue Road Version 1.10 Page 17 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 standard(s) 22 and 23. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff demonstrated awareness of their responsibilites in relation to the protection of vulnerable adults however improvement must take place with monitoring and recording systems. EVIDENCE: Two service users were asked if they knew who to talk to if unhappy or wanted to complain. One stated “the manager or staff” and the other stated, “The manager or my key worker, they are here to help me”. Staff confirmed their roles as advocates when being interviewed stating that they were their to “support individuals” and to “make them aware of their rights”. The inspector found that each service users file contained the homes complaints procedure in large print, picture format that had been signed by the service user and manager. All staff interviewed confirmed that they had undertaken Crisis Prevention Intervention and Adult Protection training however certificates were not available to validate the Crisis Prevention Intervention training. When asked how they can protect service users from abuse staff gave examples such as being aware of their needs and disabilities, listening to what they say, reporting and recording. Due to an incident that occurred previously at the home policies and practices regarding service users money and financial affairs have been re-devised with detailed risk assessments and audit trails implemented that include the Service Co-ordinator checking and counter signing the managers audits. When looking 35 Avenue Road Version 1.10 Page 18 at these records the inspector found that the manager had been maintaining her obligations to monitor records but that the Service Co-ordinator had only completed this once this year despite this being identified as a Requirement in a previous inspection. 35 Avenue Road Version 1.10 Page 19 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 standard(s) 24,25,26 and 30. The standard of the environment within this home is adequate, providing service users with a comfortable place to live. Service users bedrooms have furniture and fittings sufficient and suitable to meet individual needs and lifestyles. EVIDENCE: On the day of inspection the premises were comfortable, bright and free from offensive odours. The organisation employs a maintenance person to ensure the upkeep of the premises with a logbook completed for all work carried out. 35 Avenue Road Version 1.10 Page 20 The inspector asked a service user if they were comfortable living at the home. The service user stated, “Yes, I have my own room. I like it a mess but have to clean it. I have my own video, television, DVD player, posters and books”. The inspector was then invited to look at the service users room and found it to be individually decorated with personal items and belongings as the service user had described. The service user confirmed that they had been given a key to their bedroom and to the front door of the home but had lost these and was waiting for them to be replaced (the manager confirmed that this was in the process of being arranged). Staff interviewed confirmed their understanding that service users bedrooms are their own personal space with one member of staff stating “they choose how to decorate, put furniture where they want, choose their bed linen, everything is their choice”. The home has policies and procedures in place for the control of infection however no staff have undertaken training in this area (this requirement was identified in a previous inspection and remains outstanding). 35 Avenue Road Version 1.10 Page 21 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 35 the key standard to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35 and 36. The staff have a good understanding of the service users needs, this is evident from the positive relationships which have been formed between the staff and service users. Since the last inspection the standard of vetting and recruitment practices has improved with appropriate checks and records now being carried out. Some progress has been made in relation to training and development, further work is still required to ensure staff have the appropriate skills and qualifications to meet the needs of service users. EVIDENCE: 35 Avenue Road Version 1.10 Page 22 Many of the staff that work at the home have done so for several years building relationships with service users appropriate to gender, age and personal interests. Staff profiles are completed that detail competencies, skills and experience. The inspector found that these demonstrated that the staff group is made up of individuals from various backgrounds, with differing skills and experiences that complement the service user group presently living at the home. This was further confirmed within interviews with staff all of which were able to give detailed accounts of the needs of service users and how they support them to meet those needs from either life skills or knowledge gained through further education they had undertaken such as Learning Disability Award Framework accredited training. Since the last inspection the inspector found that staff records relating to recruitment and selection maintained at the home had improved, with all files sampled containing those required as listed in Schedules 2 and 4 of the Care Homes Regulations 2001. Although the home completes individual staff profiles and a document that lists staff training requirements for the team as a whole the inspector did not judge this to be sufficient to demonstrate that an assessment had been completed for the staff team as a whole nor did it demonstrate how training would benefit service users (a Requirement previously identified in March 2004). The inspector saw evidence that all staff receive induction training within six weeks of appointment that meets Sector Skills Council specifications. The manager and staff interviewed stated that they have undertaken equal opportunities training since the last inspection, however no certificates were available to verify this. Since the last inspection there has been an improvement in the number of supervision sessions staff receive with records verifying that staff now receive at least six sessions a year. This was further confirmed during interviews with staff who stated they receive regular supervision from the manager. When asked if they found it of value comments received included “yes, it nice to have the opportunity to talk about issues” and “find it useful, given advice”. However a previous requirement to implement a written policy in relation to supervision still remains outstanding. All staff must also have an annual appraisal in order to review their performance and agree development plans for the future. 35 Avenue Road Version 1.10 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12-month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39,42, 43. The manager encourages involvement and communication, creating a positive and inclusive atmosphere. Some progress has been made to obtain service users and their representatives views of the home. No progress has been made to supply documentation that demonstrates effectiveness and financial viability. EVIDENCE: When asked about the manager a service user stated, “she’s nice, when you have problems you can talk to her and she listens. She tells me to do independent things”. When interviewing staff they also confirmed that the manager is approachable stating that “there is a lot more interaction since the manager has been here, more meetings on a regular basis, more staff and service user involvement”. These comments were validated when the inspector checked the records for staff meetings, one to one service user meetings and the daily records. 35 Avenue Road Version 1.10 Page 24 When the inspector previously carried out an inspection at the home it was in the process of implementing a quality assurance system. During this inspection the inspector was shown completed service user surveys and family comment cards that were being used to obtain views on how the home is meeting its aims. The manager stated that these would shortly be analysed with findings published and made available to interested parties. The inspector also instructed that an annual audit of the quality assurance system must take place. The inspector examined all staffs training records and found that some held up to date moving and handling, first aid and food hygiene certificates but that no one had undertaken infection control training (a requirement that was identified it the previous inspection). Improvement had been made in relation to fire training with all staff undertaking training October 2004, with the next date booked for the end of April 2005. It was demonstrated to the inspector that the homes manager is responsible for the day to day running of the home with approval required by the organisations Service Co-ordinator for additional funding outside the normal budgets, some training, changes in policies and procedures and the purchase of large items of furniture. The organisations Service Co-ordinator also seeks approval from the Registered Proprietor. When assessing if Requirements identified in previous inspections had been addressed in accordance with the action plan supplied to the Commission for Social Care Inspection by the organisations Service Co-ordinator, the inspector found that the majority of those requiring action required involvement by higher management within the organisation. Staff confirmed to the inspector their understanding of the lines of accountability within the home and with external management. However many staff that the inspector spoke to commented that they felt the Registered Proprietors “give little support to the manager” and “give no recognition for the work care staff do at the home”. The inspector recommended that these issues be discussed within the next staff meeting. 35 Avenue Road Version 1.10 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score x 2 2 Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 2 2 Page 26 35 Avenue Road Version 1.10 21 x 35 Avenue Road Version 1.10 Page 27 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 YA1 Regulation 4 Requirement The Service User Guide must include service users views of the home (Requirement originally made June 2004) Care plans must be reviewed with the service user on a monthly basis The home must be able to demonstrate that a referral to the Speech Therapist for service user G has been made The home must be able to demonstrate that a referral to the Dietician for service user G has been made The home must ensure comprehensive health records are maintained and are kept up to date Service users must be weighed every month and the findings recorded Comprehensive assessments must be completed to determine if service users can self administer medication Staff must sign for all medication they administer Medication Administration records must be completed in full Version 1.10 Timescale for action 31/07/05 2. 3. YA6 YA19 15 12(1) 30/05/05 30/04/05 4. YA19 12(1) 30/04/05 5. YA19 12(1) 30/04/05 6. 7. YA19 YA20 12(1) 13(2) 30/04/05 31/07/05 8. 9. YA20 YA20 13(2) 13(2) 14/04/05 14/04/05 35 Avenue Road Page 28 10. YA23 10(1) 11. YA23 10(1) 12. YA35 18(1) 13. YA35 18(1) 14. YA36 18(2) 15. 16. YA36 YA39 18(2) 24 17. 18. YA39 YA39 24 24 19. YA42 13(3-6) All service user records pertaining to finances must be regulary audited and monitored by a person other than the manager (Requirement originally made June 2004) The home must be able to validate that staff have undertaken physical intervention training The home must be able to validate that all staff have undertaken equal opportunities training The home must ensure a training needs assessment is completed for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning (REQUIREMENT ORIGINALLY MADE MARCH 2004) The home must implement a policy regarding supervision (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) All staff must receive an annual appraisal The home must implement an annual development plan (REQUIREMENT ORIGINALLY MADE MARCH 2004) An annual audit of the quality assurance system must take place The results of service user surveys and families/carers questionaires must be analyised and and included in the quality assurance system All staff must undertake moving and handling, first aid, food hygiene and infection control training (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) Version 1.10 30/04/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 31/07/05 35 Avenue Road Page 29 20. YA 43 25 The home must implement a financial plan that is open to the CSCI for inspection and that is reviewed annually (REQUIREMENT ORIGINALLY MADE MARCH 2004) 31/07/05 21. 22. 23. 24. 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 YA8 YA43 Good Practice Recommendations It is recommended that service user meetings occur on a regular basis in order that service users are consulted on, and participate in all aspects of life in the home It is recommended that the Registered Proprietors attend a percentage of staff meetings in order that staff can give and receive direct feedback 35 Avenue Road Version 1.10 Page 30 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 35 Avenue Road Version 1.10 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!