Inspection on 12/07/06 for 41 Bryndale Avenue

This inspection was carried out on 12th July 2006.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

41 Bryndale Avenue 22/02/08

41 Bryndale Avenue 31/01/06

41 Bryndale Avenue 13/09/05

41 Bryndale Avenue 18/01/05

41 Bryndale Avenue 16/09/04

41 Bryndale Avenue 17/02/04

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 Bryndale Avenue, 41 Flats 13, 14 & 18 Kings Heath Birmingham West Midlands B14 6NQ Lead Inspector Kerry Coulter Unannounced Inspection 12th July 2006 09:40 Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bryndale Avenue, 41 Flats 13, 14 & 18 Address Kings Heath Birmingham West Midlands B14 6NQ 0121 441 3982 F/P 0121 441 3982 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) Sense West Miss Karen Tracey Roberts Care Home 3 Category(ies) of Learning disability (3), Sensory impairment (3) registration, with number of places Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service Users must be aged between 18-65 years The service may provide personal care only for three (3) persons with a learning disability and sensory impairments That the manager undertakes a minimum of 21 hours dedicated management/administration time a week. 31st January 2006 Date of last inspection Brief Description of the Service: Flat 13, 14 and 18 Bryndale Avenue are part of a complex of flats which have been purpose built by Moseley and District Housing Association. A number of the flats are leased by SENSE in the Midlands and registered as care homes. The flats accommodate three service users with a sensory disability. The accommodation is situated on the first and second floor of the block and the flats each comprise of a hall, bedroom, bathroom, lounge and kitchen. Access to the accommodation can be gained by the main staircase. The flats are situated amongst other registered and non-registered provision. Disabled access is poor; the flat is not suitable to anyone with mobility difficulties. To the front of the flats there is off road parking. There is a small communal garden, which is shared with other SENSE registered flats at Bryndale and Shalnecote Grove. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the field work visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. A pre inspection questionnaire was sent to the Manager but this was not returned to the CSCI prior to the inspection visit. The unannounced fieldwork visit was carried out over seven hours. This was the homes key inspection for the inspection year 2006 to 2007. The inspector spoke with staff, two service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: Prospective new service users have the opportunity to visit the home and assessment is completed prior to moving in to ensure the home can meet their needs. Support is given by staff in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. It is good that care plans contain clear guidance for staff on how to offer choice to each service user. All care plans sampled included detailed information on the support required for personal care, for example support needed when bathing and preferences to include things such as the use of skin care products. This ensured staff have clear guidance on how to meet each individuals needs. Staff actively promoted contact with service users relatives. People who live at the home take part in a variety of daytime activities including swimming, music, art, rock climbing, gym and ice-skating. The staff have had lots of training to help them meet the needs of the people who live there. Suitable adaptations have been made to the home to ensure it meets the needs of individuals with a sensory impairment. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 6 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. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users needs and aspirations are assessed appropriately before an offer of placement is made. EVIDENCE: The service user guide and statement of purpose were observed to be available. Since the last inspection the statement of purpose has been updated. The Manager agreed to send a copy of this to the CSCI. The service user guide includes photographs and reports received from the provider show that work is underway to transfer this to CD Rom to make it more accessible and interesting for service users. A referral and admission policy is available and a summary of the admission process is included in the statement of purpose. SENSE benefits from having the services of a Referral and Information Manager who receives any initial referrals. No new service users have been admitted since the last inspection. Evidence from the last inspection showed that full assessment was completed prior to the move, this included the service user, relatives and health professionals. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Service user needs are generally reflected in their individual plans. Risk assessments are not available for all areas of risk to fully or accurately underpin service users needs or the risks they face. Service users are consulted on how they wish care and support to be provided, where this is not possible advocacy services have been used. EVIDENCE: The care plans and risk assessments for two service users were sampled. The care plans contained detailed information to include history, medical needs, likes and dislikes, care routines, communication ,issues of diversity and culture. Information was up to date. During the inspection visit the Practice Development Worker was observed to be working on further developments to the plan for one service user who is quite new to the home. Each service user has a core team of staff, who meet monthly, to monitor the care plan, progress on achievements, goals, health care and to action any points. Minutes of these core meetings were available in the files sampled. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 10 Behaviour management strategies were observed to be detailed and included possible triggers for behaviours and strategies for staff to use to try and prevent the behaviour occurring. Review of one strategy was needed to ensure it linked in with the guidelines for the administration of ‘as required’ medication, this is further detailed in the medication standard of this report. At the last inspection it was identified that one individual had been given notice of termination of their accommodation at the home due to funding issues with the care purchasers. Due to this service users communication needs it would be difficult for staff to make them fully aware of the situation and their options. It was therefore required at the inspection that staff seek an independent advocate to represent the service user through this difficult time. This has now been done and the advocate has met with the service user. The risk assessments sampled were variable in their quality. For one service user their assessments were up to date and areas of risk had been satisfactory assessed. For another service user the majority of assessments had not been reviewed in the last six months and some activities with potential risk had not been assessed, for example rock climbing and ice skating. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. People living in the home experience a meaningful lifestyle and are offered a healthy and varied diet. Contact with family and friends is facilitated, both in and out of the Home. EVIDENCE: Service users have a weekly schedule for planned activities. This is backed up by written guidelines on the support required for each scheduled activity. A vehicle is provided for service users to access the community. They also are supported to use public transport. Discussions with staff and sampling of records evidence that a wide range of activities are on offer both in house and in the community. On the day of the inspection one service user went out shopping and to Church. One service user spoken with regarding activities on offer said they were happy and were doing lots of new activities, this included ice skating, rock Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 12 climbing and bowling. They also had lots of photographs that showed them participating in and enjoying these activities. There was evidence that service users are fully supported by staff to maintain contact with relatives. One service user showed some artwork that they had been supported by staff to do, they said the work was intended as presents for family. This individual later went out with staff to post a letter to a relative. It is an area of good practice that SENSE employs a Family Liason Officer. Regular newsletters are sent out to relatives. Additionally, a family weekend is arranged annually at a local hotel where relatives can meet with SENSE representatives and other relatives. Where restrictions are placed on service users this is linked to risk assessments and care plans. For example, each individual has guidelines for items they will not tolerate in their bedrooms such as chairs or window blinds. Records of meals provided showed that a variety of food is offered. Food provided and menus are appropriate to and reflect the cultural background, and likes and dislikes of the individuals who live in the home. Adequate food stocks were available and these included fresh fruit and vegetables. One service user said that they go with staff to the shops to choose their food. They also said that staff had got them a special machine that enables them to make hot drinks safely. The machine bleeps when there is enough hot water in the cup so that the service user knows when to stop pouring in the water. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Some aspects of how individuals’ health needs are supported are in need of improvement. The systems for the administration of medication require improvement to ensure service users medication needs are safely met. EVIDENCE: Individual care plans detailed the support that staff needed to give to service users in relation to their personal hygiene. One care plan stated that the person likes to have their hair braided and then detailed how staff should do this. Service users were dressed appropriately to their age, the weather and the activities they were doing. Each person had their own individual style of dress. Each service user had an individual Health Action Plan. This is a personal plan about what support a person needs to stay healthy and access the relevant healthcare services. Some plans needed improvement to fully reflect the current support needed. For example, for one individual the plan said that they needed to see the Nurse every three months for their diabetes but the plan did not show this was being done. The Manager said that this individual now did not need input three monthly but this change had not been recorded on the Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 14 plan. Another plan said the service user needed chiropody input six weekly, whilst the record did show regular chiropody it was not six weekly. The Manager said the plan should have stated six to eight weekly. Medication was observed to be stored appropriately. Copies of prescriptions are now being retained as required at the last inspection so that staff can check the correct medication has been received from the chemist. Medication administration records sampled were generally satisfactory but unfortunately the record for one service user had not been signed for medication administered the previous day. Written protocols were available for medication prescribed on an ‘as required’ basis. These need to be dated to show that the guidance is current. Records and discussion with staff show that one service user is being given medication ‘as required’ for their behaviour on a frequent basis. Guidance in place for this was a little confusing and did not clearly relate to the behaviour management strategy. The protocol did not make it clear that alternative methods should be tried before medication is administered. However discussion with the Manager, Deputy and one support staff did show that they were aware of distraction methods to use before resorting to the use of medication. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for making complaints are satisfactory to ensure that service users views are listened to and acted on. Arrangements are sufficient to ensure that service users are protected from abuse. EVIDENCE: The home has a satisfactory complaints procedure. This was produced in a format that included both written words and symbols and stated that it was also available on a CD so making it more accessible to the service users. It included all the relevant and required information including details of how to contact the CSCI to make a complaint. The CSCI has not received any complaints about this home since the last inspection. Copies of the Birmingham Multi Agency Adult Protection guidelines and the homes adult protection flowchart were observed to be readily available to staff. Staff receive adult protection training. Sampled recruitment records for three members of staff show that all the necessary checks are done for staff before they start work in the home, ensuring the right people are working with service users. Information regarding the suitability of agency staff is also retained in the home. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 16 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, 29 and 30 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is comfortable, safe and homely. Their individual flat is kept clean and tidy and standards of hygiene are satisfactory. EVIDENCE: The home is made up of three individual flats. Each service user has their own kitchen, lounge/diner, bedroom and bathroom. There is access to a small communal garden which is shared with other registered homes, this is not ideal. The flats were observed to be clean with no unpleasant odours noticeable. The standard décor of each flat was satisfactory and all were personalised according to the individual preferences and needs of the service user who live there. One service user spoken with said that they were happy with their flat. Two of the flats have had new settees since the last inspection making the lounge areas more comfortable for the service users. Records show that shortly before the inspection visit one service user tore areas of their bedroom Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 17 and lounge carpet, these areas were observed to have been made safe. The Manager said that as the purchasers of the care service were intending to move this individual from the home in a few days time the carpet would be repaired when they had moved, as to do it now would cause unnecessary disruption for this individual. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 18 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): 32, 33, 34, 35 and 36 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements ensure that service users are supported by satisfactory numbers of appropriately trained and supported staff to meet their needs. EVIDENCE: It was noted that both staff and tenants appear comfortable in each other’s company and enjoy a good general rapport. They give support with warmth, friendliness and patience and treat people respectfully. The pre inspection questionnaire completed by the Manager indicates that 50 of staff have completed an NVQ in care. Staff employed at the home reflect the gender and culture of service users at the home to ensure their needs can be met. Sampled rotas show that adequate numbers of staff are provided to support service users. One service user has 2:1 staffing however SENSE is only funded for 1:1 staffing and so this has caused some difficulties, as detailed earlier in this report. Staff recruitment files were sampled. These contained all the information as required by regulation to include satisfactory evidence that a CRB check had been obtained. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 19 Sense as an organisation have a rolling programme of training. Home managers apply for places for staff on training courses with the training coordinator. Discussions with the Manager indicate a positive attitude towards training and development of the care team. Staff spoken with said they received the training they needed. The home retains copies of training certificates of staff and has a training matrix that shows all the training completed by staff, this is regularly updated. Records show that staff have received the mandatory training they need, evidence was seen that for new staff training needed has been scheduled. Supervision records for three staff were sampled, these showed that the quality of supervisions is good and the frequency regular to ensure staff are well supported in their job role. In Flat 18 staff generally are on duty on their own. It is therefore important that they get to meet on a regular basis with other staff to discuss issues that are important to them and to the smooth running of the flat. This was not being done at the last inspection. Records sampled at this visit show that staff meetings for these staff are now being arranged. As recommended at the last inspection written guidance for Flat 18 staff has been produced detailing the procedure they need to follow when wanting to take a break. The Manager will need to check that the procedure takes into account the European Working Time Directive. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager communicates a clear sense of direction and leadership. Work practices generally promote and protect service user’ welfare, health and safety but attention is required to fire safety and review of risk assessments. EVIDENCE: The home has a Registered Manager who has completed an NVQ 4 in care and is now working towards completing the Registered Managers Award. It was clear from looking at outcomes for service users and her response to issues raised during the inspection that the Manager directs staff to ensure that service users needs are met. Systems are in place to assure quality. This includes monthly visits to the home by a service manager who completes a report. Audits are also carried out periodically to include health and safety, financial, environment and outcomes for service users. Action plans are then completed. Records showed Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 21 that these had been evaluated recently to monitor progress towards agreed actions. Sense as an organisation has also developed a staff development plan that covers induction and staff training. Fire records showed that staff had tested the fire alarm on a weekly basis. As previously required staff are testing the emergency lighting monthly to ensure it is working and service users are kept safe in the event of a fire occurring. A fire drill was overdue, this had last been done in December and was due to be done in June. The monthly report from the Sense representative visiting the home in June had identified a fire drill was due, this therefore should have been done. Fire training had been done with most staff as required at the last inspection, some new staff needed training and this has been booked. The fridge and freezer temperatures are taken daily and these were within safe food storage limits. Water temperature records showed that staff test these weekly and that water is kept at a safe temperature. A certificate was available to evidence that gas appliances were safe in Flat 18 but the certificates for Flat 13 and 14 could not be located. The Manager said she would forward them to the CSCI when they were located. Risk assessments had been completed for the environment and staff, most of these were up to date and satisfactory, a minority required review as they had last been evaluated in January 2005. Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 22 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 3 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 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 23 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 YA6 Regulation 12(1)15 Requirement The registered manager must ensure that behaviour management guidelines are reviewed so that they link clearly to guidance on the use of ‘as required’ medication. The registered manager must ensure that all areas of risk to service users are satisfactorily assessed and that risk assessments are reviewed at least six monthly. Health action plans need further development to fully reflect the current support needed. The registered manager must ensure that staff sign the medication administration record after medication has been administered to service users. Timescale for action 30/08/06 2. YA9 12(1) 13(4) 30/08/06 3. YA19 12(1,a) 13(1,b) 13(2) 30/08/06 4. YA20 30/07/06 Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.R01.S.doc Version 5.2 Page 24 5. YA20 13(2) 6. YA42 13(4) 23 13(4) 13(4) 7. 8. YA42 YA42 Written protocols for the administration of ‘as required’ medication must be dated on production to show the guidance is current. Ensure all protocols are clear in their instructions and link in with behaviour management strategies. Ensure fire drill are conducted at least six monthly with a record maintained in the fire log. A copy of the gas certificate for flats 13 and 14 must be forwarded to the CSCI. The registered manager must ensure all risk assessments for the environment and staff are reviewed at least every twelve months. 30/08/06 15/08/06 30/08/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA9 Good Practice Recommendations The introduction of the ‘traffic light’ system to highlight level of risk on risk assessments. (Previous recommendation) Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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: 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 Bryndale Avenue, 41 Flats 13, 14 & 18 DS0000017158.V304640.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. Re-publishing this information is in breach of the terms of use of that website. 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