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Inspection on 20/09/06 for Flaxman Avenue (77) - City of York Council

Also see our care home review for Flaxman Avenue (77) - City of York Council for more information

This inspection was carried out on 20th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home and its staff are very welcoming. The service is well managed and run. The environment is clean and comfortable making it a pleasant environment to be in. Staff communicate well with service users and there is a relaxed, friendly atmosphere. Service users are clearly supported to maintain independence and control over their lives. The care provided is of a high standard and service users are treated with respect and dignity. Service users enjoy staying at Flaxman Avenue and relatives and professionals consulted with all speak very highly of the service.

What has improved since the last inspection?

The registered manager is monitoring the quality of care and actively seeking feedback from service users about the service.

What the care home could do better:

The registered person still needs to establish and maintain a professionally recognised quality assurance system. A report of any reviews conducted should be made available to service users and a copy forwarded to the Commission for Social Care Inspection.

CARE HOME ADULTS 18-65 Flaxman Avenue (77) - City of York Council 77 Flaxman Avenue Tang Hall York North Yorkshire YO10 3TW Lead Inspector Donna Burnett Key Unannounced Inspection 20th September 2006 02:30 Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Flaxman Avenue (77) - City of York Council Address 77 Flaxman Avenue Tang Hall York North Yorkshire YO10 3TW 01904 426428 F/P 01904 426428 carole.aherne@york.gov.uk 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) City of York Council Mrs Carole Ann Aherne Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Flaxman Avenue is registered to provide residential, personal, and social care on a respite basis for up to 6 adults with learning disabilities. 2 of the beds are for emergency admissions and whilst service users can be provisionally booked into them as part of their rolling respite programme, it is on the understanding that if an emergency situation arises, the respite stay may be cancelled at short notice. The home is a single storey purpose built property owned by the City of York Council. All of the bedrooms are of single occupancy, three have en-suite bathrooms and three have en-suite toilets. There is currently a six-person day service being run from the lounge at the front of the home. This is staffed separately from the care service and finishes at 3.30pm so does not interfere with the respite care provision in the home. The home is located on the outskirts of York City centre, in a residential area, with good access to the City’s services and amenities. There is a large car park to the front of the home and an enclosed garden at the back of the property. The responsible individual is Mr Daryoush Haj- Hajafi and the registered manager is Mrs Carole Aherne. The full cost of a weeks stay at Flaxman Avenue is £1097.90. The charge to service users is based upon income, including benefits and capital. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is the result of an unannounced visit to the service on 20th September 2006. The visit took place over five hours; a further four hours were spent preparing for the inspection and gathering information about the service. All of the key standards were looked at during the inspection. A pre-inspection questionnaire was completed and returned to the Commission for Social Care Inspection prior to the visit to the service and provided information, which is included in the main body of the report. Four Social Services Care Managers and four relatives of people who use the service gave comments and feedback about the service. The visit was timed for mid afternoon to allow time to speak with the manager and staff on duty prior to the service users returning to the home following their usual daily activities. The manager, Carol Aherne, was available throughout the inspection. It was also possible to talk to four other members of staff and all six of the service users currently in respite care. One requirement and two recommendations were made following the last inspection, all of which have been addressed. A further requirement and another two recommendations were made as a result of this inspection. What the service does well: What has improved since the last inspection? The registered manager is monitoring the quality of care and actively seeking feedback from service users about the service. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 6 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. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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): 2. Quality in this outcome area is good. Staff have sufficient information about people using the service to be able to provide the specific care and support that each person needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All prospective service users are assessed by a Social Services Care Manager prior to coming to the home. The manager obtains a written copy of the assessment so that staff are left in no uncertainty about each persons individual needs. Service users are able to spend time at the home and meet the staff before making a decision about whether or not to use the service. The service user guide is easy to read, available in different formats and makes good use of pictures for people who have difficulty reading. It provides good information about what service users can expect from their stay at Flaxman Avenue. Service user plans are drawn up which identify specific care needs. They include any agreement that has been made with the service user in terms of any potential restrictions that may have to be imposed, usually on health and safety grounds. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 & 9. Quality in this outcome area is good. The care provided to service users is of a good standard and allows service users to make their own decisions about how they live their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plans clearly identify social, personal and health care needs so that staff know what help and support to give. Risk assessments are incorporated into the plans and detail service users’ preferences about how they wish to live their lives. Plans are reviewed and updated to reflect changes in need. The most up to date service user plans which were looked at, however, had not been signed by the service users so it could not be evidenced that they had been involved in the drawing up of their plans. There are few restrictions and limits for people staying at Flaxman Avenue. The service users and/or family members acting on their behalf agree to any restrictions that are imposed, such as limits on alcohol consumption. Information is given about advocacy and how to make contact should a service user wish to access independent advice and support. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 10 Service users have choice about many things including when they go to bed, when they get up, what they eat and where they eat it. They are supported to manage and keep safe any money they choose to bring into the home. Meetings are encouraged and provide a good opportunity for people staying at the home to influence and have their say about how the service is run. Risks identified prior to admission are clearly documented on service users plans. Staff are clear about the risks that individual service users have the right to take and what precautions need to be taken to minimise the risk of harm. Service users wishing to participate in activities such as showering or bathing unaccompanied, using the laundry and kitchen, are assessed for their level of risk and steps taken to manage those risks safely. The home is run and organised in such a way that the potential of harm to service users from the immediate environment is low. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 & 17. Quality in this outcome area is excellent. Service users are supported to enjoy the lifestyle they choose. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged to continue with their usual attendance at specialist day centres or work placements but also have the opportunity to participate in personal shopping, laundry and household tasks whilst at the home. There are sufficient opportunities to pursue other interests outside of the home and appropriate activities and social stimulation are on offer for anyone choosing not to go out. During the inspection one service user chose to go out for the evening whilst somebody else planned to demonstrate some recently acquired line dancing skills. A number of service users spoken to enjoy visits to the pub, into town and to local attractions. Adequate staffing levels mean that at present this can be usually be arranged on an ad hoc basis at the request of the service user. Staff have access to a car and a mini bus in order to assist service users to enjoy a variety of leisure activities. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 12 Service users are encouraged to maintain family and social contact throughout their stay at Flaxman Avenue and visitors of their choice are welcomed into the home. A telephone is available for use as is a computer. If staff are out of the building they are contactable on a mobile telephone so that messages can still be passed on. Relationships are supported, and where possible, service users are able to choose when they want to stay at the home. The home is run in such a way so as to promote independence rather than foster dependence. Service users are permitted to use the laundry facilities, but in the presence of staff, for health and safety reasons. Staff enter individual service users bedrooms at their request and are respectful of the need for privacy. There is sufficient space in the home for people to either be alone or in company. There is a no smoking policy, which is clearly detailed in the service user guide and is there to provide a safer and healthier environment for people staying at the home. A small number of service users have requested and chosen to have monitors in their bedrooms to enable staff to hear if they are in distress and unable to ask for help using any other means. Where this is the case it has been clearly recorded in the service users plans that this is their choice and that they consent. The use of call bells and other assisted technology has been explored but not found to be a suitable alternative. Service users are encouraged to help plan, shop for, prepare and serve meals. The manager is in the process of displaying a board with pictures of food on it so that service users can use visual aids to select their meal. There is always a choice of food, and during the inspection five service users chose to have curry for tea, whilst another service user was able to request something different. Staff have very good knowledge of, and there are written details about, special dietary needs, likes and dislikes. The food served looked appetising, was well presented and plentiful. No one required assistance but the manager gave assurance that service users requiring specialist feeding are appropriately assisted and catered for. The dining area provides a very pleasant and sociable environment in which to enjoy a meal. The well-equipped, spacious kitchen is wheelchair accessible and service users can help themselves to food and drink as and when they want it. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 & 20. Quality in this outcome area is good. Service users receive good support from well-trained staff and have access to specialist services when required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff promote the independence of the service users and provide support in a sensitive manner. Service users preferences as to how they wish to be supported are recorded within individual care plans. A key workers system means that service users and their family have a designated member of staff to relate to. Specialist aids and equipment are available for service users so that independence can be maximised. A well-established, consistent staff team ensures continuity for people using the service. Some service users choose to maintain responsibility for their own medication and are supplied with a lockable cupboard to be able to do so safely. Healthcare needs that arise are responded to and dealt with promptly by a staff group who are well trained, experienced and knowledgeable. Records are kept of any changes to service users physical and emotional health needs and are communicated to staff coming on duty during a handover period. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 14 Medication brought into the home, administered and returned by staff is clearly documented so as to avoid mishandling. Stock balances are kept to minimise the risk of errors. Medication is safely and appropriately stored and staff are suitably trained. Records are not kept however of medication, which service users keep themselves for self-administering. This means that staff and health professionals may not always be able to relate any changes in need, mood or behaviour to the effects or omission of prescribed medication. A bottle of eye/drops did not show when they were opened and there is a risk that they may still be used when out of date. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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 & 23. Quality in this outcome area is good. People who use the service are able to express their concerns, have access to a robust complaints procedure and are protected from abuse and harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users and their families are informed of their right to complain. The complaints procedure is summarised within the service user guide and gives clear information about who to speak to if you are unhappy. Contact details for the advocacy service and the Commission for Social Care Inspection are also provided. Concerns and comments received by the home are documented and the action taken recorded. Commendations are also recorded so that the staff team can be made aware of what they are doing wrong, what needs to be put right and what they are doing particularly well. One comment from a relative was that ‘staff are friendly and helpful and deal with any problems/queries efficiently’. None of the relatives who returned comment cards had ever had cause to make a complaint, and the Care Managers who responded were not aware of any complaints about the service either. Staff are trained in adult protection and the City of York Council have an Adult Protection Policy to follow in the event of any suspicion or allegation of abuse. A whistle blowing policy encourages workers to raise concerns about possible malpractice. Staff are checked for any criminal records before being employed and are rechecked regularly to ensure that service users are cared for by staff who have been suitably vetted. Service users who have the potential to display extreme or inappropriate behaviour are known to staff and the interventions necessary to minimise the risk of harm to others are clearly documented. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 16 The service user guide is clear about what will happen if certain behaviour upsets the routine of the home or other users of the service. Bullying is not tolerated and a policy is available for people wishing to look at it in detail. Records, possessions and money handed over for safe keeping are stored securely. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. The design and layout of the home enables service users to enjoy a safe, well-maintained and comfortable environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home provides spacious, non-institutionalised accommodation for service users. It offers access to local amenities, transport and support services. Bathrooms are suitably equipped to deal with the safe lifting and manoeuvring of service users and there are ample toilets. Adaptations and specialist equipment are unobtrusive and do not detract from the homely environment. The kitchen is suitably adapted to allow people in wheelchairs use of the facilities. The home is clean, comfortable, and safe and during the inspection was free of any offensive odours. It is decorated and furnished to a very good standard. The décor and furnishings reflect a ‘young persons’ type of accommodation and personal items are encouraged to make bedrooms more individualised. When possible, service users are given choice over which room they wish to stay in. There is access to a very pleasant rear garden, which also has a seating area. A range of maintenance and safety checks are completed on a regular basis to make sure that the house and its facilities are safe and secure. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 18 The laundry is appropriately sited so as to minimise the risk of spread of infection. Access is restricted to ensure the safety of the service users. Care staff are also responsible for the cleanliness of the home. Domestic duties are undertaken either on a night or during the day when the majority of service users are out of the building. This does not impact on the service users being able to receive the care they need when they want it. The home was observed to be very clean and hygienically maintained throughout. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 36. Quality in this outcome area is good. Sufficient staffing levels, proper recruitment procedures and good staff training mean that service users are well supported and their needs met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels during the inspection were sufficient for meeting the needs of the service users. Service users social activities are not compromised due to the availability of staff at peak times of the day. At night there is one person doing sleep-in duties whilst one staff member stays awake. The staffing levels are flexible and vary according to the needs of the service users at any given time. Throughout the inspection all members of staff showed interest and commitment to the service users. A good understanding of individual service users needs was shown. The staff group are long serving with many years experience in this area of work and offer a good mix of skills. Many have achieved recognised caring qualifications. There is very little use of relief staff, which ensures continuity of care for people staying at the home. Three staff files were looked at. Robust recruitment and induction procedures are followed which ensure that service users are cared for by people who are suitably trained and vetted. Criminal Records Bureau checks are redone regularly to confirm staff’s ongoing suitability to work with a vulnerable client group. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 20 Training is appropriate for the needs of the service users and there is plenty of it available. Records are kept of all training and training needs are also identified through regular supervision. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42. Quality in this outcome area is good. The service is managed and run in the best interest of the people who use it. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is a qualified nurse with twenty years experience in her field. She has run the home for several years and shows competence, leadership skills and a commitment to the service users. The home is run in an organised but not restrictive manner, which allows the service users to have their say. Comments and feedback are encouraged and acted on. The manager regularly looks at and reviews the quality of the service based on the views of the service users. Unmet needs are recorded so as to identify shortfalls within the service. Both complaints and commendations are documented and action taken to deal with any concerns that are raised. Regular meetings with the service users and staff allow for feedback and suggestions about what the service could do better, what changes people would like to see and what they like best. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 22 A questionnaire has recently been developed by the manager asking how service users feel about coming to stay at Flaxman Avenue. Service users were available to talk to in private during the inspection and gave very positive views of the service. Whilst the manager can evidence some monitoring of the service and is actively seeking feedback, the use of a professionally recognised quality monitoring system and internal audit by the City of York Council would show a stronger commitment to review the services available. Some records were looked at and other information was provided with the pre -inspection questionnaire, which showed that equipment is maintained. Gas and electricity supplies in the home are safe and serviced appropriately. Fire detection and fire fighting equipment is tested and maintained regularly and fire drills have been satisfactory in evacuating service users safely and quickly. Staff receive training with regard to all health and safety matters. Potentially hazardous substances are stored carefully and access to areas containing such substances is restricted. There was evidence of compliance with relevant health and safety legislation. Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 2 X 3 3 2 X X 3 x Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13(1)(b) 13(2) 17(1)(a) Schedule 3(3i) Requirement A record must be kept of all medication brought into the home, even when service users are self-medicating and looking after their own medication. Timescale for action 28/11/06 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 YA6 Good Practice Recommendations Service user plans should be signed by the service user to show that they have been consulted with and agree with the content of the plan. The date on which ear/eye drops are opened should be noted on the bottle so that they can be destroyed after the recommended amount of time. This protects service users from harm, which could be caused by administering out of date medication. The City of York Council should take steps to support the registered manager in developing a system which regularly reviews the quality of care provided at the care home. 2. YA20 3. YA39 Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Flaxman Avenue (77) - City of York Council DS0000034930.V311656.R02.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!