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Inspection on 02/11/05 for Avenue The (3)

Also see our care home review for Avenue The (3) for more information

This inspection was carried out on 2nd November 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 16 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

Staff at the home must ensure all residents have a holiday of their choice. During the inspection, staff were seen to interact with residents with courtesy and respect. One resident said, "its great here, staff are really nice, sometimes I get a bit fed up but the staff and other people living in the home are all friendly, and that helps me``.

What has improved since the last inspection?

During the last visit, a number of requirements were made regarding the recording and administration of medication. It was pleasing to see these requirements have been met.

What the care home could do better:

More information needs to be available to residents pertaining to what financial help is available to them concerning holidays. Audits of financial records must be completed on a regular basis. There must be clear guidelines in respect of whose responsibility it is to replace or repair items of furniture if worn or broken. Health and Safety issues for the protection of residents must be reviewed on a regular basis and adequate records maintained. Training records must show what training staff have received and what training is required. Complaints must also be acknowledged in writing and the outcome must also be completed in writing to the complainant.

CARE HOME ADULTS 18-65 Avenue The (3) Acocks Green Birmingham West Midlands B27 6NG Lead Inspector Susan Scully Unannounced Inspection 2nd November 2005 09:00 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Avenue The (3) Address Acocks Green Birmingham West Midlands B27 6NG 0121 693 0182 0121 693 0185 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) Kelso Care Consortium Limited Miss Sophie Kay Donnelly Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years That Miss Donnelly completes her Registered Managers Award by April 2005. 29th June 2005 Date of last inspection Brief Description of the Service: 3 The Avenue is registered to provide personal care and support to 10 adults with a learning disability who have been assessed as requiring full assistance with daily living tasks. The home is staffed 24 hours a day including waking night and a sleeping in member of staff. Service users would be admitted to the home following a full assessment that would determine the level of support they require. The full range of medical services, leisure and social activities are provided for the service users. A number of adaptations have taken place within the home in order to meet the assessed needs of the service users. Service users are encouraged and supported to maintain links with their families and the local community. The care needs of the service users are monitored and reviewed and action is taken to address any concerns. The home is in a residential road close to Acocks Green shopping centre. There are a number of local bus routes. The railway station is a five-minute walk away. The Avenue is ideally placed to access Birmingham city centre and a number of smaller shopping centres. Acocks Green offers a wide choice of local community facilities and places of worship. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over one day. Records pertaining to the Health and Welfare of residents were sampled. Including care plans, activities records, daily records and reviews. Health and Safety records were sampled including risk assessments pertaining to residents and the environment. Residents were consulted about the care provided, and every day activities. 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. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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): 3, 5 Residents have the necessary information to enable them to make an informed choice. Each resident has a contract of terms and conditions of residency. EVIDENCE: Care plans sampled showed residents are consulted regarding their preferences, likes and dislikes. There have been no new admissions since the last inspection. The admissions procedure indicates a trail visit would take place with an over night stay. An assessment by a representative of the home would be completed before admission. Each resident has a contract of terms and condition of residency, however the residents do not always sign these. At the last inspection it was identified that contracts needed to include the contribution the provider makes towards residents holidays. This was not assessed during the visit. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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): 6, 10 Care plans sampled did not give accurate information pertaining to the residents’ capabilities in respect of understanding and functioning in every day living tasks. Residents must be made aware of their rights to see what information is held about them. EVIDENCE: A plan of care is generated in consultation with the resident, other healthcare professionals and families when required. The plans of care sampled set out the current and anticipated care needs and how these will be met. In daily records, there were some recordings that were inappropriate such as being told off. When speaking with the manager and provider one resident was described as being unable to fully understand the concept of information given to him. In the plan of care there were no indications of this resident having this problem and indeed showed the resident to be totally independent and able to fully understand all aspects of daily living. Care plans must be clear and give information that is not contrary to what staff and others believe. One resident said he did not know what information was held about him but he knew the staff would tell him if he asked. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 9 If a resident does not fully understand information given to them then measures must be taken to ensure the resident is protected. The care plan must reflect this. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 10 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): 12, 13, 15 Further information is required pertaining to the opportunity of a career choice. Each resident is encouraged to participate in activities of their choice. Resident’s rights and choice is respected. Staff ensure the residents take responsibility with support for the decisions they make. EVIDENCE: Records sampled show residents attending colleges and activities of their choice. There were no records or information to show if residents were assisted to maintain careers advice, or how they develop employment skills. Residents do participate in activities such as holidays and go out regularly. Staff ensure residents maintain links with family and friends. The manager said residents choose who they want to see. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 11 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): 20 Medication monitoring is maintained to a satisfactory standard. Risk assessments concerning residents who self-administer creams or inhalers are not completed. EVIDENCE: Medication records are maintained to a satisfactory standard. The administration records showed what medication comes in to the home and that all medication is checked against medication as indicated on the doctor’s prescription. A record is maintained of current medication for each resident. Staff who administer medication have had suitable training in Safe Handling and Administration. Protocols and risk assessments are required for all residents who may wish to self-administer medication and this to include creams and inhalers. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 12 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 complaints procedure is adequate. All complaints are not acknowledged in writing or the complainants are not given the outcome causing the complainant to feel their views have not been listened to. EVIDENCE: The commission had received a complaint regarding allegation of the theft before the inspection and this was looked at during the visit further. Records were sampled pertaining to the complaint that showed the manager had conducted an investigation in accordance with policies and procedures. The manager had not kept notes of the interviews held with staff. The manager said information was written down in a general format after speaking with staff. The relative and resident who had made the complaint records showed consultation was maintained throughout the investigation. The police were informed and social service. The commission completed an investigation into the allegation of the theft and other components in relation to the complaint. There was insufficient evidence to uphold the complaint. Standard 14 of the National Minimum Standard specifies as part of the basic fee there is an option of a minimum seven-day holiday out side the home, which the residents help choose and plan. In the Service Users Guide, this has been omitted from the contract and is seen as an additional charge. Records pertaining to the contribution made by the provider towards the cost of holidays were not examined during the visit and requirements are carried forward from the last inspection. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 13 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, 26 Further provisions are required to ensure suitable access to the property is accessible for wheelchairs users. Bedrooms are clean and personal to the individual residents. EVIDENCE: The home was comfortable and decorated to a satisfactory standard. Residents have a choice of two lounges one has recently been decorated. One resident said they had helped to choose what colours the walls would be and had been consulted about the décor of the other lounge. Bedrooms were personal to the individual appeared to reflect their personality. The home was clean and fresh. There is a concern regarding the entrance to the property with steps to the front door and this has been brought to the provider’s attention. The Manager must ensure there is accessibility for wheelchair access. The provider said they do have a ramp that they can be put down if required. It was brought to the inspector attention this ramp is not suitable for all wheelchairs users particular family and friends of one resident. A further assessment must be completed. An agency for domiciliary care is provided in the building via the main stairs and resident’s bedrooms. The provider has no documentation to show how resident’s privacy is protected. The provider must produce a policy to ensure staff from the agency do not infringe upon residents privacy when visiting the home. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 14 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): 35, 36 Training records do not reflect the training needs of staff or show what training is in date. Supervision is completed on a regular basis. When a concern is identified in supervision this is not dealt with in accordance with polices and procedure. EVIDENCE: Staff files sampled contained information pertaining to the suitability of the employee. Records were seen for CRBs references, photos, medicacal fitness, application form, and identification. Training records required updating to include all mandatory training completed. Supervision records showed supervision takes place on a regular basis. One file contained information to say the member of staff had left the building without permission to conduct a personal matter. There was no information to say the outcome of what the manager did or if action was taken. This resulted in the home not having the required amount of staff on duty for this period while the member of staff was out. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 15 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): 39, 42 Health and Safety pertaining to prevention of scalding or burns is not sufficient to ensure the Health and Safety of residents. Policies and procedure are adequate. A procedure must be produced to show the steps to take when an incident occurs. EVIDENCE: Polices and Procedures are reviewed on a regular basis. Equipment such as Electrical Safety testing is completed. Regular testing of fire alarms and fire drill are completed. A policy is required for a step-by-step guide of how to conduct an investigation if any concerns are raised in a complaint. The high surface temperatures of radiators and specific needs of some service users present a risk. Protective covers must be fitted as appropriate to all radiators. Showers must be regulated to prevent scalding. Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Avenue The (3) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000016988.V264492.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5(1)(b) Requirement The Service User Guide must include details about holidays and what contribution the organisation makes. Compliance not assessed. Previous time scale 01/08/05. Care plans must show accurate information pertaining to the resident’s capabilities in communication and understanding of the information given to them. Where this is not possible, alternative measures must be sought. The home must ensure that daily records indicate care offered, care received and response to care. The home must also address the inappropriate language included in some entries. Previous time scale 01/08/05. Non Compliance. Information is required in more detail in care plans to show how the needs of residents are being met. Resident must be made aware of their rights to see what information is held about them. DS0000016988.V264492.R01.S.doc Timescale for action 01/01/06 2. YA6 14(1)& 15(1) 01/12/05 3. YA6 14(1)& 15(2)(a) 01/12/05 4 YA6 15(2)(b) 01/12/05 5 YA10 15(1) 15(2) (a) 01/12/05 Avenue The (3) Version 5.0 Page 18 6 YA13 16(2)(m) 7 YA20 13(4) (c) 8 YA22 22(3) 9 YA23 13(6) 10 11 12 YA24 YA35 YA36 23(2)(n) 18(1)(c) 18(2) 13 YA37 9(2)(b)(i) 14 YA39 13(6) 15 YA42 13(4) (c) 16 YA42 13(4) (c) Support and information must be given to residents to enable them to seek guidance in respect of activities and employment if they wish to do so. Risk assessments must be completed for all residents who self-administer medication, creams or inhalers. All complaints must be acknowledged and a written response given of the findings of any investigation completed. All residents’ financial records must show the contribution made by the provider towards holidays. Compliance not assessed. The building must have provision to ensure access for wheelchair users. Training records must be updated and reflect the training completed by staff. Action must be taken when issues of concern are identified during supervision and recorded to show the outcome. The manager must complete NVQ level 4 both in management and care by 2005. Compliance not assessed. A policy giving a step-by-step guide in how to conduct an investigation into complaints must be completed. Protective covers must be fitted to all radiators that present a possible risk of scalding. Previous time scale 01/08/05. Compliance not assessed. All showers must be regulated to prevent scalding. Previous time scale 01/08/05. Compliance not assessed. 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/12/05 01/01/06 01/01/06 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 19 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 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Avenue The (3) DS0000016988.V264492.R01.S.doc Version 5.0 Page 21 - 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!