Inspection on 17/02/04 for 41 Bryndale Avenue

Care Homes For Adults (18 ­ 65)Bryndale Avenue, 41 Flats 13 & 14Kings Heath Birmingham West Midlands B14 6NQAnnounced Inspection17th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Bryndale Avenue (41) Flats 13 and Flat 14 Address Flat 13 &14 Bryndale Avenue Kings Heath, Birmingham, West Midlands, B14 6NQ Email Address Tel No: 441 3982 Fax No: 441 3982Name of registered provider(s)/Company (if applicable) Sense HQ (South B`Ham) Name of registered manager (if applicable) Dave Sanders Type of registration Care Home No. of places registered (if applicable) 2Category(ies) of registration, with (number of places) Learning disability (2), Sensory impairment (2) Registration number E060000074 Date First registered 1st August 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 1st August 2002 YES YES OCTOBER 2003 If Yes Refer to Part CBryndale Avenue, 41 Flats 13 & 14Page 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 317th February 2004 11:00 ­ 18:45 Donna AhernID Code071637Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionBryndale Avenue, 41 Flats 13 & 14Page 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementBryndale Avenue, 41 Flats 13 & 14Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Bryndale Avenue, 41 Flats 13 & 14. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Bryndale Avenue, 41 Flats 13 & 14Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Flat 13 and 14 Bryndale Avenue is 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 two service users with sensory disability. The accommodation is situated on the first floor of the block and the flats each comprise of a hall, bedroom, bathroom, lounge and kitchen. In flat 14 there is a sleep in room and a staff office in flat 13. Access to the accommodation can be gained by the main staircase. The Flat is 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 flat there is off road parking. There is a communal garden, which is shared with other SENSE registered flats at Bryndale and Shalnecote Grove.Bryndale Avenue, 41 Flats 13 & 14Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection took place over one long day. One service user went out for part of the day to a workshop session, and the other service user went out briefly to the local shops. The inspection included observation of care practice including one service user being supported to prepare her evening meal. The inspector was introduced to both service users and some basic finger spelling interactions took place. It was not possible to have conversations with either service users due to communication needs. The staff had informed both service users of the visit and line drawings were saw in both flats which gave some explanation of the inspection visit. The inspection was generally positive. There was evidence of on going progress on requirements identified at the unannounced inspection in October 2003. Choice of Home (Standard 1-5) All five standards were assessed. Three met the required standard two had minor short falls. The home has a statement of purpose, aims and objectives for the home and a service user guide. These have recently been updated to reflect the current service. The service user guide now includes a copy of the tenants agreement and details of additional charges. It must also include details of the terms and conditions/contract with SENSE. Discussions with staff and the manager at the time of the inspection demonstrated that they are aware of the individual needs of the two service users. Sampling of care plans indicated that referrals are made to other professionals including dietician, G.P, psychiatrists and diabetic nurse as required. Reviews and assessments of the service users needs are held annually. The manager confirmed that service users relatives and other agencies are invited to attend or to have an input to these meetings. The manager has recently developed a goal and aspiration format, which aims to link the care plan and review meetings. The inspector was informed that contracts/statement of terms and conditions have historically been held at Senses head office in Wakefield. These must be available in the home on each service users file. SENSE requires that 60 of service users mobility DLA Allowance is contributed towards the homes transport costs. This must be included in the contract. Individual Needs and Choices (Standards 6-10) All five standards were assessed. Three met the required standard, two had minor short falls. The home has continued to develop its care plan process. There was detailed information in respect of each service users history, medical needs, likes and dislikes, care routines, communication needs, goals and aspirations, and review meeting. Sampling of daily records Bryndale Avenue, 41 Flats 13 & 14 Page 6 indicates generally good recording, however some recordings that the inspector saw were not sufficient in detail and did not reflect response to care and choices, this requires addressing. Recordings by waking night staff and staff on sleep-in duty required clarification, and must be linked to the risk assessment for the support at night service users require from waking night staff. These entries must be signed by the care staff and must reflect the support given and the service users response. It is also good practice for all staff to sign and date each of the care plans as evidence they have read and will comply with it. The manager confirmed at the time of the visit that the risk assessments are being restructured and that ongoing development work is taking place. The support required by service users during the night require reviewing to ensure that they make explicit the support required and how this must be given to service users. Lifestyle (11-17) All seven standards were assessed. Six met the standard required, one had some minor shortfalls. There was evidence from sampling service users care plans and discussions with staff that service users do have the opportunity to attend educational facilities and activities. The inspector saw an activity schedule for both service users. In each of the flats there is a music system and a television. The inspector was informed that services users also enjoy some cooking and domestic tasks. A masseur visits the flats on a weekly basis to carry out a massage service. The inspector was informed that one of the service users also enjoys make-up and pampering sessions. One of the service users did not go on holiday this year. The inspector was informed that this was due to staff changes. One service user went to Spain. It is anticipated that holiday breaks will be planned for next year. Staff confirmed at the time of visits that they are also currently exploring new home based activities for the service users to take part in. Personal and Healthcare Support (Standards 18-21) All four standards were assessed as meeting the standard. Sampling of care plans indicated that there is evidence that both service users health care is monitored. Both service users are registered with the local GP and records are kept of all health appointments. Records include appointments with the GP psychiatrists, chiropodist and diabetic nurse. The home has an accident procedure, and accident books are in place for service users, staff and visitors to the home. Concerns, Complaints and Protection (Standards 22-23) Both standards were assessed and one had minor shortfalls. Additions are required to the Complaint and Adult Protection Policy as detailed in the requirement section of the report. Environment (Standards 24-30) All seven standards were assessed. Five met the required standard, two had some shortfalls. There has continued to be improvements to the physical standards of the home. This includes refurbishment of both kitchens, painting and decorating of the hallway, bedrooms and lounge area. A new shower has been installed in flat 14. The inspector was advised that refurbishments of the bathrooms are to take place in early March 2004. Progress has been made on the outstanding work to the fire panel to separate the system so that each provision has its own fire panel. The manager informed the inspector that this work Bryndale Avenue, 41 Flats 13 & 14 Page 7 is to take place during the first week in March 2004. The current manager has appropriately pursued a number of outstanding matters in relation to the environment. This has required considerable negotiation with the homeowners Moseley and District. The homes own environmental audit/risk assessment identified the need to install a userfriendly intercom, to further explore colour contrasting. Staffing (Standards 31-36) Five of the six standards were assessed, Two met the required standard three had some shortfalls. The inspector met with two support staff, one acting deputy and the manager at the time of the visit. All staff presented as having an understanding of the aims and objectives of the home and of the homes policies and procedures. The inspector was informed that all staff has job descriptions. Staff and managers spoken to at time of the visit were able to clearly demonstrate their knowledge and commitment to the homes aims and values. The inspector was informed and staff rotas examined indicated, that there was a minimum of one support worker in each flat per shift (07.00-14.30) (14.00-22.00). At night there is one waking night staff in flat 13 and one undertaking a sleeping in duty, in flat 14. The inspector was informed that a reassessment of one of the service users needs and required staffing levels is currently taking place with the placing authority. The NCSC must be kept informed of developments. Conduct and Management of the home (Standards 37-43) All seven standards were assessed. Four met the required standard and three had minor shortfalls. The manager has several years experience in the field of visual impairment and has NVQ Level 4 in Management and Care. The registered manager is also the registered person for 41 Bryndale and Shalnecote Grove. This arrangement has been satisfactory to date, however the NCSC will continue to review the situation at future inspections. The registered manager demonstrated a good understanding of health and safety issues. Further developments in respect of risk assessment documents are required as detailed in the requirement section of the report.Bryndale Avenue, 41 Flats 13 & 14Page 8 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 1 23(4) YA24 Fire Alarm Panel The Alarm panel is linked to other registered services in the complex. The panel is situated within the office at Shalnecote Grove. Each registered service must have its own integrated fire system. 2 18(2) YA4 Policy and Procedures for admissions. The homes admission policy requires some additions. A minimum three-month `settling in period of residence must be offered for long-term placements. This should be followed by a review with the service user of the trial placement, during which existing users are consulted about the compatibility of the prospective new service user. 3 5(1)(b)(c) YA5 Contract A copy of the contract/Terms and Conditions must be available in the home. 4 12(1)(13) (6) YA23 Adult Protection Minor additions are required to the policy, as follows; It needs to make explicit in its updated/revised guidance that both the Area Office, where the home is located and the placing authority of the service user, must be informed in the event of any Adult Protection Matter. (Birmingham Multi Agency Guidelines). Bryndale Avenue, 41 Flats 13 & 14 Page 9 Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Bryndale Avenue, 41 Flats 13 & 14Page 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 13(4)(a)(b) (c) YA9 Ongoing development of service users risk assessments are required including service 17/4/04 user bedrooms and aspects of daily living and community activities. Fire Alarm Panel The Alarm panel is linked to other registered services and the panel is situated within the office at Shalnecote Grove. Each registered service must have its own integrated fire system. Policy and Procedures for admissions. The homes policy requires some additions; 3 18(2) YA4 A minimum three-month `settling in period of residence must be offered for long-term placements. Followed by a review with the service user of the trial placement, during which existing users are consulted about the compatibility of the prospective new residence. Contract 4 5(1)(b)(c) YA5 A Copy of the contract/Terms and Condition Must be available on service users files. 28/4/2004 28/4/2004223(4)YA2430/3/04Bryndale Avenue, 41 Flats 13 & 14Page 11 Adult Protection Minor additions are required to the policy as follows; 5 12(1)(13) (6) YA23 It needs to make explicit in its updated/revised guidance that both the Area Office, where the home is located and the placing authority of the service user must be informed in the event of any Adult Protection Matter (Birmingham Multi Agency Guidelines). Staff files must include copies of, YA34 · · Birth Certificate Passport 24/02/2004 17/03/2004 28/4/200467,9,19 Schedule2 (1)(2)715(2)YA6Daily records must reflect choice and response to care. The home must review the recording by waking night staff/sleep in staff. A review of the rota and staffing levels is required to ensure flexibility of staffs working patterns and allow for activities at the evening and weekends to take place.18/02/2004818(1)(c)YA3331/03/2004923(3)YA24Refurbishment of bathrooms in flat 13 and 14. (The inspector was informed at the time of the 31/03/2004 inspection that Moseley and district will complete this work week beginning 1/3/04) Some minor additions are required to the complaint procedure must be included in the policy: that a complainant can contract the NCSC at any stage in their complaint process if they wish to do so. Complaints must be responded to in 28 days.5 (1) (e)& 22 (1) 10 17 (2) Schedule 4 11 YA2228/4/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s)Bryndale Avenue, 41 Flats 13 & 14Page 12 No.Refer to Standard *Good Practice Recommendations1YA28There are no separate bathroom facilities for staff they access the service users bathroom in each of the flats. This arrangement continues to be reviewed and guidelines are in place The home must explore producing information in suitable formats for the service users who live at the home2YA1* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Bryndale Avenue, 41 Flats 13 & 14Page 13 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES YES 2 0 2 NO YES YES YES X X 17/2/04 11:00 7.45Bryndale Avenue, 41 Flats 13 & 14Page 14 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Bryndale Avenue, 41 Flats 13 & 14Page 15 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 1458.72 3119.99 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are 60 DLA Mobility contributed to homes vehicle 2 Key findings/Evidence Standard met? The home has a statement of purpose, aims and objectives for the home and a service user guide. These have recently been updated to reflect the current service. The service user guide now includes a copy of the tenants agreement and details of additional charges. It must also include details of the terms and conditions/contract with SENSE. Physical standard shortfalls are made explicit in the statement of purpose (staff share service users bathroom and facilities). The manager confirmed that the organisation is in the process of producing the information in a format suitable for service users. Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The current service users have lived at flat 13 and 14 for a few years. The inspector was informed that assessments were undertaken prior to admission. The manager demonstrated awareness of the requirements of the National Minimum Standards in relation to prospective service users. The assessments were not examined at the time of the inspection.Bryndale Avenue, 41 Flats 13 & 14Page 16 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Discussions with staff and the manager at the time of the inspection demonstrated that they are aware of the individual needs of the two service users. Sampling of care plans indicated that referrals are made to other professionals including dietician, G.P, psychiatrists and diabetic nurse as required. Reviews and assessments of the service users needs are held annually. The manager confirmed that service users relatives and other agencies are invited to attend or to have an input to these meetings. The manager has recently developed a goal and aspiration format, which aims to link the care plan and review meeting. Monthly core team meetings take place which are a forum for staff directly involved in the service users care, to review that persons care plan on an ongoing basis. Service user involvement in the care planning process is limited due to their complex communication needs. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 2 Key findings/Evidence Standard met? Senses admission policy and procedure must be amended so that it includes a three-month `settling in period for new service users, followed by a review with the service user of the placement. The nature of the service at flat 13 and 14 would indicate that unplanned admissions to the home are unlikely. The manager demonstrated that he has a good awareness of the required admissions process in line with the national minimum standards, and that these would be applied in the event of a prospective service user being referred to the home. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? The inspector was informed that contracts/statement of terms and conditions have historically been held at Senses head office in Wakefield. These must be available in the home on each service users file. They should contain all the required information as stated in the National Minimum Standards and must be signed by the service user and the registered manager. SENSE requires that 60 of service users mobility DLA Allowance is contributed towards the homes transport costs. This must be included in the contract.Bryndale Avenue, 41 Flats 13 & 14Page 17 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? The two service user files were sampled at the time of the inspection and there continues to be evidence of ongoing development of the care plan process. There was detailed information in respect of each service users history, medical needs, likes and dislikes, care routines, communication needs, goals and aspirations, and review meeting. This information was observed to be current. Sampling of daily records indicates generally good recording, however some recordings that the inspector saw were not sufficient in detail and did not reflect response to care and choices, this requires addressing. Recordings by waking night staff and staff on sleep-in duty required clarification, and must be linked to the risk assessment for the support at night service users require from waking night staff. These entries must be signed by the care staff and must reflect the support given and the service users response. It is also good practice for all staff to sign and date each of the care plans as evidence they have read and will comply with it. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Sampled service user care plans indicated that there was evidence that service users are consulted. This was also observed on the day of the inspection. One service user, when asked, made the decision not to go to an IT session that morning. Alternatives were offered and this information was clearly recorded on the daily records.Bryndale Avenue, 41 Flats 13 & 14Page 18 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The inspector was informed that service users do not currently participate in the development of policies and procedures because of their communication needs. Some of the SENSE policies are available to staff in other formats. The inspector was informed that service users do not participate in the recruitment and selection of new staff. Observed practices and discussions with staff at the time of the visit indicated that service users are encouraged to make choices and decisions about their day-to-day life. Flat 13 and 14 are clearly each of the service users own home. There was evidence through observations at the time of the visit and sampling of the care plans that service users are encouraged to choose and cook their own food and take part in a range of domestic tasks with the required support from staff. Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Risk assessments on service users were sampled and progress has been made since the previous inspection. Risk assessments have been established for each of the service users bedrooms specifying any shortfalls in the minimum furniture and fittings as required by the National Minimum Standards. The manager confirmed at the time of the visit that the risk assessments are being restructured and that ongoing development work is taking place. The support required by service users during the night require reviewing to ensure that they make explicit the support required and how this must be given to service users. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 3 Key findings/Evidence Standard met? The manager and staff spoken with at the time of the visit demonstrated a good understanding of confidentiality matters. Records were observed to be stored appropriately in the office in flat 13. In flat 14 a small cupboard stores daily records and the service users care plan. The organisation has a confidentiality policy.Bryndale Avenue, 41 Flats 13 & 14Page 19 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Through discussions with staff and managers at the time of the visit, they were able to describe how service users are encouraged to maintain and develop social, emotional, communication and independent skills. This was evidenced by direct observation at the time of the visit. There was observation of excellent communication from both staff with both of the service users. Through the course of the day one service user was prompted with personal care, wrote a letter to her family, was supported to go to the Post Office to buy a stamp and send the letter, chose and helped prepare her lunch and tea, and to do domestic tasks in her flat including putting laundry away and washing up. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? There was evidence from sampling service users care plans and discussions with staff that service users do have the opportunity to attend educational facilities and activities. The inspector saw an activity schedule for both service users. One service user attends a workshop in Oldbury specifically geared towards the needs of people with dual sensory impairment. The inspector was informed that she really enjoys attending the workshop and gets fully involved with making wooden items. There were photograph displayed in her flat, which illustrated some of the work she has completed. She also enjoys a weekly rambling session and an Information Technology session. The other service user attends Drama therapy and an Information Technology session and is about to commence a numeracy class at Bournville College.Bryndale Avenue, 41 Flats 13 & 14Page 20 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The inspector was informed that the service users enjoy community-based activities. The home has a mini bus, which is accessed by both service users. The inspector was informed that a mini bus is the risk assessed required mode of transport due to behavioural needs of one of the service users. The manager aims to ensure a driver is on each shift to support community-based activities. However there are sometimes difficulties with this. The manager is therefore working on an `action plan to ensure access to the community is not limited due to drivers. He stated at the time of the visit that public transport for one service user is to be explored, as well as the use of community ring and ride and taxis. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? In each of the flats there is a music system and a television. The inspector was informed that services users also enjoy some cooking and domestic tasks. A masseur visits the flats on a weekly basis to carry out a massage service. The inspector was informed that one of the service users also enjoys make-up and pampering sessions. One of the service users did not go on holiday this year. The inspector was informed that this was due to staff changes. One service user went to Spain. It is anticipated that holiday breaks will be planned for next year. Staff confirmed at the time of visits that they are also currently exploring new home based activities for the service users to take part in. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Both service users have contact with their family. Staff stated that family contact is encouraged. The home has a visitor policy, which is displayed and welcomes visitors between 10.00 and 22.00hrs. The inspector was informed that SENSE has a family liaison officer who provides counselling and support to service users families.Bryndale Avenue, 41 Flats 13 & 14Page 21 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Each service user has their own flat and full access to all areas. Both have a locked storage/COSHH cupboard. Some restrictions are in place based on risk assessments. The inspector was advised that on occasion some kitchen cupboards would be locked for safety reasons for a short period. The television in flat 13 has a Perspex cover for safety reasons. The television in flat 14, which for safety reason was on a raised wall bracket, has been lowered since the unannounced visit and it is anticipated that further progress will be made on this matter. At the time of the inspection both service users were supported to participate in the daily routine of their own flat. The inspector was informed that one service user indicates clearly when she wants staff to leave her flat. The flats do not have a private garden but do have access to a small communal garden, which is also accessed by other registered flats in the complex. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Each of the service users does their own weekly shop. They then choose daily what they want to cook and eat with support from staff. A record of food served is recorded daily on the daily records and included drinks and snacks so that a full overview of each service users intake could be seen. The inspector observed one service user prepare her own tea with verbal and some physical prompt from staff. The inspector had a discussion with staff in respect of how a healthy diet is promoted with each service user. Staff confirmed that they encourage a balanced and varied meals. Both service users can eat without physical assistance from staff.Bryndale Avenue, 41 Flats 13 & 14Page 22 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The home does not provide nursing care. There is no lifting or handling adaptations therefore the flats would not be suitable for someone with mobility difficulties. There are documented guidelines in respect of personal care on service users care plans. Clearly there are some personal needs of service users that are best met within a single service facility.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? Sampling of care plans indicated that there is evidence that both service users health care is monitored. Both service users are registered with the local GP and records are kept of all health appointments. Records include appointments with the GP psychiatrists, chiropodist and diabetic nurse. The home has an accident procedure, and accident books are in place for service users, staff and visitors to the home. These were observed to be compliant with the new data protection legislation.Bryndale Avenue, 41 Flats 13 & 14Page 23 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? Each flat has its own wall mounted lockable cupboard for the storage of medication. Records were seen for medicines received, administered and disposed of. Each service users medical file had details of their medication and information of side effects. Protocols are in place for medication administered on an as required basis. The manager confirmed that some staff are still waiting to access the accredited medication training at Solihull College, however the manager informed the inspector that the courses are currently full. In the interim, the manager completes in house medication competent assessments, on each staff member. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? The inspector was informed that the organisation has two documents that are sent out to families to complete if they wish to do so, in respect of their wishes in the event of death of their relative. This form has been forwarded where possible to the relevant relatives. The organisation also has the service of a family liaison officer to support relatives and staff with such matters.Bryndale Avenue, 41 Flats 13 & 14Page 24 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 0 0 0 0 0 0 2 Key findings/Evidence Standard met? Some minor additions are required to the homes. `Summary complaints procedure it must make explicit: that a complainant can contract the NCSC at any stage in the complaint process if they wish to do so. Complaints must be responded to in 28 days. The complaint procedure must be in a format suitable for the service users who live at the home.Bryndale Avenue, 41 Flats 13 & 14Page 25 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence Minor additions are required to the policy as follows; It needs to make explicit in its updated/revised guidance that both the Area Office, where the home is located and the placing authority of the service user must be informed in the event of any Adult Protection Matters (Birmingham Multi Agency Guidelines). YESX Standard met? 2Bryndale Avenue, 41 Flats 13 & 14Page 26 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? Both of the flats were maintained to a satisfactory standard. There has continued to be improvements to the physical standards of the home. This includes refurbishment of both kitchens, painting and decorating of the hallway, bedrooms and lounge area. A new shower has been installed in flat 14. The inspector was advised that refurbishments of the bathrooms are to take place in early March 2004. Progress has been made on the outstanding work to the fire panel to separate the system so that each provision has its own fire panel. The manager informed the inspector that this work is to take place during the first week in March 2004. The current manager has appropriately pursued a number of outstanding matters in relation to the environment. This has required considerable negotiation with the homeowners Moseley and District. The homes own environmental audit/risk assessment identified the need to install a userfriendly intercom, to further explore colour contrasting and to refit radiator covers.Bryndale Avenue, 41 Flats 13 & 14Page 27 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 2 0 0 0 2 00 0 0 03 Key findings/Evidence Standard met? Each flat has a single bedroom, lounge area and small kitchen. There is a bathroom with a toilet in. In flat 13 there is a staff office, which stores records for both flats. In flat 14 there is a sleep in room for staff.Bryndale Avenue, 41 Flats 13 & 14Page 28 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms do not contain all the required fixture and fittings as detailed in the National Minimum Standards. The inspector was informed that this is due to the needs and wishes of individual service users. A risk assessment for both bedrooms has now been completed. The manager confirmed that these will be continually reviewed and updated, and where possible additions and improvements to the bedrooms will be made as and when tolerated by the service users.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 2 Key findings/Evidence Standard met? Each flat has its own bathroom facility, but both require refurbishment this has been scheduled for March 2004. There are no separate bathroom facilities for staff they access the service users bathroom in each of the flats. This arrangement continues to be reviewed and guidelines are in place. Staff were observed asking permission from the service user to use the facility. This shortfall is in the homes statement of purpose. The home was registered before April 2002, so these matters are now raised as a recommendation. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? Both service users have their own bedroom, bathroom, kitchen and lounge. It is not shared with any other service user. As stated in standard 27 there are no separate bathroom facilities for staff they access the service users bathroom in each of the flats. This arrangement continues to be reviewed and guidelines are in place.Bryndale Avenue, 41 Flats 13 & 14Page 29 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? There was evidence that some environmental adaptations have been made in accordance with the needs of the individual service user including adapted furniture, doorbells and décor with colour contrast. Work to upgrade the fire alarm system and include beacons in all rooms is scheduled for March 04. In addition, the manager confirmed that their own environment risk assessments identified the need to install a user-friendly intercom, and to further explore colour contrasting in line with the ongoing improvements of the flats.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The flats were observed to be clean and hygienic on the day of the visit. The washing machine in each flat is located in the kitchen area for the sole use of the service user. The tumble drier is located in the room that is now used as the staff office in flat 13. Progress has been made in flat 13 in relation to the service user tolerating fixed toilet roll holders. There are plans to progress on these matters with the aim of toilet roll and towel dispensers being permanently fixed in the bathroom.Bryndale Avenue, 41 Flats 13 & 14Page 30 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? The inspector met with two support staff, one acting deputy and the manager at the time of the visit. All staff presented as having an understanding of the aims and objectives of the home and of the homes policies and procedures. The inspector was informed that all staff has job descriptions. Staff and managers spoken to at time of the visit were able to clearly demonstrate their knowledge and commitment to the homes aims and values. The inspector was informed that there are currently no volunteers working at either flat 13 or 14 Bryndale Avenue.Bryndale Avenue, 41 Flats 13 & 14Page 31 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 2 X X X 5 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X 444 X Nursing X X XXX2 Key findings/Evidence Standard met? The flats share a staff team who work in both flat 13 and 14. At the time of the visit the inspector was informed that the deputy manager is off on long term sick. Her role is to oversee the day to day running of the two flats. One of the support workers has been appointed to acting deputy to support the manager in his role, as he is the manager for a number of services (Shalnecote flats, 41 Bryndale Avenue). The inspector was advised that currently there are no vacant posts at the flats. Agency staff is used to support staffing levels. Both the manager and the staff on duty at the time of the visit recognised the need and importance of consistent staffing.Bryndale Avenue, 41 Flats 13 & 14Page 32 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 2 Key findings/Evidence Standard met? The inspector was informed and staff rotas examined indicated, that there was a minimum of one support worker in each flat per shift (07.00-14.30) (14.00-22.00). At night there is one waking night staff in flat 13 and one undertaking a sleeping in duty, in flat 14. The inspector was informed that a reassessment of one of the service users needs and required staffing levels is currently taking place with the placing authority. The NCSC must be kept informed of developments. Discussions with the manager at the time of the visit confirmed that the rota is currently under review to ensure that staff does not work with the same person on each shift but that there is some flexibility of who staff work with. In addition, the inspector raised the need for a review of the rota to ensure that there is some flexibility of staffing levels, particularly at weekends and evenings to allow for activities to take place in the community. The inspector was informed at the time of the visit that one service user likes to go out or stay out longer than the other service user. The one service user should be able to do this, equally so if one of the service user wants to return to her flat. Appropriate staffing levels need to be in place to allow this to happen. The manager confirmed that the rota and staffing levels are being reviewed. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector sampled a number of staff files in relation to the recruitment process. Two written references are obtained before staff commences employment. Copies of application forms were available. All but one file had copies of the required birth certificate and passport. There was evidence that checks by the Criminal Records Bureau for established staff had been actioned.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed at this inspection.Bryndale Avenue, 41 Flats 13 & 14Page 33 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Sampled staff files indicated that regular supervision does take place with minutes available. Staff with whom the inspector met at the time of the visit spoke very positively about the management support in the home from both the acting deputy and the manager. The home has written grievance and disciplinary procedures in place, which are available for staff to access in the office.Bryndale Avenue, 41 Flats 13 & 14Page 34 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. YES3 Key findings/Evidence Standard met? The manager has several years experience in the field of visual impairment and has NVQ Level 4 in Management and Care. The registered manager is also the registered person for 41 Bryndale and Shalnecote Grove. This arrangement has been satisfactory to date, however the NCSC will continue to review the situation at future inspections.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The inspector received positive comments from staff in respect of the management approach. Staff spoke to at the time of the visit felt that they could approach the manager. They felt he was proactive and committed to the development of the service at flat 13 &14.Bryndale Avenue, 41 Flats 13 & 14Page 35 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? This standard was not fully assessed at the time of this inspection. The inspector was informed that SENSE have an internal quality audit tool which largely influences the homes policies, procedure and administration systems. The inspector was informed that the organisation has an audit panel and a staff focus group. The organisation has also had independent audits of some of its services in the Birmingham area. The recently appointed PDW (Practice Development Workers) are responsible for internal auditing of Care Plans and communication systems. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 2 Key findings/Evidence Standard met? Policies and procedures were seen to be available in the staff office and accessible to staff. Some minor amendments are required to some of the sampled policies and procedures.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 3 Key findings/Evidence Standard met ? Service users records, and records that are required to be kept in a registered home are all currently kept in the office located within flat 13. The sampled records were generally well maintained.Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The registered manager demonstrated a good understanding of health and safety issues. Further developments in respect of risk assessment documents are required as detailed in the requirement section of the report. The home must review the environment risk assessment every six months (date completed 12/2/04).Bryndale Avenue, 41 Flats 13 & 14Page 36 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The flats are part of the SENSE organisation, which is a national registered charity. Business and financial plans for the home were not examined at the time of the inspection. A current certificate of employers liability was on display and up to date at the time of the visit. Monthly visits by the owner representative to monitor all aspects of the home were available in respect of the care providers (apart from a report for November 2003). The manager confirmed that regular meetings have now been set up with Moseley and district that are the landlords of the flats.Bryndale Avenue, 41 Flats 13 & 14Page 37 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDonna Ahern Jane RumbleSignature Signature SignatureBryndale Avenue, 41 Flats 13 & 14Page 38 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Bryndale Avenue, 41 Flats 13 & 14Page 39 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 17th February 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBryndale Avenue, 41 Flats 13 & 14Page 40 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by one month of receipt of this report, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOBryndale Avenue, 41 Flats 13 & 14Page 41 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Bryndale Avenue, 41 Flats 13 & 14Page 42 - 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. 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