Inspection on 10/11/05 for 17 Park Avenue

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

17 Park Avenue 08/04/10

17 Park Avenue 12/01/10

17 Park Avenue 17/02/09

17 Park Avenue 23/11/07

17 Park Avenue 26/01/07

17 Park Avenue 25/05/06

17 Park Avenue 16/05/05

17 Park Avenue 24/01/05

17 Park Avenue 23/11/04

17 Park Avenue 17/03/04

17 Park Avenue 09/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Park Avenue, 17 Hockley Birmingham West Midlands B18 5ND Lead Inspector Julie Preston Announced Inspection 10th November 2005 09:45 Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Park Avenue, 17 Address Hockley Birmingham West Midlands B18 5ND 0121 523 3712 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) Park Avenue Limited Mr Mohammed Anwar Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents must be aged under 65 years with a mental disorder One named service user over 65 years with a mental disorder can be accommodated whilst his needs can be met at the home. Staff at the home do not administer insulin, and healthcare professionals are contacted to provide this support where the service user cannot self administer. That the home can care for one named service user in need of care due to physical disability and mental health needs. (1PD/MD) The details regarding how his specific care and social needs will be met must be included in the service users plan. 16/05/05 3. Date of last inspection Brief Description of the Service: 17 Park Avenue is a care home for up to 22 adults that are experiencing mental health problems. The home is situated close to local amenities such as shops, places of worship and public transport links. There are six shared bedrooms and ten single bedrooms, none of which have en suite facilities. There are two lounges on the ground floor, one of which is a designated smoking area. The home has a passenger lift and there is ramped access to the front of the building. Some adaptations have been made to bathrooms to enable service users with a physical disability to shower and bathe. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and included discussion with service users and staff about the way care is delivered within the home. The inspector had the opportunity to spend time with a deaf service user that has support from a deaf member of staff in order to find out how the home meet his communication needs. Care plans and risk assessments that describe the way in which service users needs are assessed and met were sampled as well as staff recruitment and training records. A tour of the premises was undertaken and the inspector had a meal with service users and staff. This report should be read in conjunction with the report made following the visit of 16/05/05. What the service does well: What has improved since the last inspection? What they could do better: Care plans and risk assessments are in need of review and development for some service users. There are some repairs and maintenance issues that need to be addressed for the comfort and safety of people living in the home. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 6 Adult protection procedures and staff training opportunities in this area are poor and place service users at risk of harm. Equipment that is necessary for a service user to be alerted to the fire alarm had been broken and not replaced. Staff recruitment records are poor and do not protect the service users living there. Staff training records are not well maintained and some training has not been provided to enable staff to work effectively with service users. There are concerns about the content of the fire evacuation procedure, staff training in fire safety and fire safety practice. West Midlands Fire Service has been alerted to this concern. 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. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 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 Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 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 Service users needs are assessed by social and healthcare professionals prior to them moving into the home. The homes own assessment procedures are in need of development. EVIDENCE: The home’s assessment procedures used prior to a potential service user’s admission were examined and were found to be in need of development. The procedure that was in place made reference to the Registered Homes Act (1984), which is now, obsolete. Two new service users have been admitted to the home since the last inspection and evidence was seen within records that an assessment of their needs had been made by social and healthcare professionals prior to them moving into the home. In one case adaptations had been made to the home to enable the service user to have access to appropriate bathing aids and equipment in accordance with his assessed needs. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 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 Individual plans of care and risk assessments are in need of development to clearly describe how service users needs are to be met within the home. Service users have opportunities to make decisions about their lifestyles. EVIDENCE: The care plans for two service users admitted to the home within the last six months were sampled. There has been some development of the clarity of information within individual plans since the last inspection. Both plans were seen to identify service users needs with regard to personal care, mobility, community access, manual handling and culture and religion. There were however a number of areas within both plans that require further work to ensure that staff have accurate information upon which to meet service users assessed needs. For example, in one plan it was recorded that the service user was at risk of pressure sores. There was no evidence of a pressure relief plan, nor details of proactive strategies to minimise the risks of this occurring. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 10 Within the same plan it was recorded that the service user required assistance from staff to change position during the day and night, however the night care plan stated that hourly “corridor” checks should be conducted and assistance provided every three hours “if in need of help”. This is insufficient information to instruct staff how to meet service users needs. In another plan it was recorded that the person should only go out with staff and should have no unsupervised outings. There was no risk assessment in place to support this judgement and furthermore, it was noted that the service user had been out, unsupervised to fetch newspapers on more than one occasion. It was of concern, upon reading daily records for this service user that a number of entries referred to incidents of challenging behaviour. There was no detail in the individual plan to instruct staff how to manage the behaviour nor any proactive strategies in place to avoid the risk of the behaviour taking place. Immediate requirements were made that this issue be addressed by the home within one week of this inspection. It was pleasing to note that some care plans had been translated into Punjabi to enable staff that speak this as a first language to understand the content of the plans. Sampling of daily records and discussion with service users and staff demonstrated that service users are supported to make decisions about their care and lifestyles. Service users made positive comments about being enabled to choose college courses that they were interested in and make decisions about how to spend their money. The inspector was impressed with the support provided to a deaf service user. The home employs a part time member of staff who works specifically with this service user to enable him to access community based activities. The member of staff confirmed that the home has a minicom system that the service user has access to. Evidence was seen in the records of house meetings that service users have been supported to make choices about the activities they take part in. For example, trips to Drayton Manor Park and other places of interest. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 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 There are opportunities for service users to take part in activities that they enjoy. EVIDENCE: The home has made progress to offer meaningful activities to service users. Individual plans sampled showed that service users activity preferences had been recorded and examination of daily records demonstrated that these activities had been offered on a regular basis. Discussion with a number of service users indicated that they have opportunities to visit places of worship in accordance with their religious beliefs. The inspector spoke to two service users who described going out swimming and to play pool every week, which they both enjoyed. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 12 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 Service users personal care needs are clearly recorded and service users receive their personal care according to their preferred routines. Individual plans that describe service users health care needs are in need of development to clearly identify how these needs are to be met. EVIDENCE: The individual care plans sampled showed that service users needs with regard to their personal and health care had been assessed, although some areas of health care planning were seen to require further development. In one plan, there was no information about how to support a service user who was described as at high risk of falling nor strategies in place to reduce the risk of this occurring. In the same plan there was no information to describe the person’s mental health care needs. It was however pleasing to note that a comprehensive exercise programme for a service user with a physical disability had been developed in conjunction with recommendations made by physiotherapy services. Records were seen which evidenced that the exercise programme was implemented on a regular basis. The inspector spoke to a number of service users who confirmed that times for getting up and going to bed were flexible. Evidence was seen in daily records and following discussion with service users that they are supported to shop for their own clothing and toiletries. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 13 The personal care plans sampled showed that service users routines and preferences with regard to the manner in which their care is delivered had been assessed. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The home has a complaints procedure, which is made available to service users and their families. Service users understand how to raise complaints should they wish to do so. The home’s adult protection procedures are poor and place service users at risk of harm. EVIDENCE: The home has a complaints procedure which, it was reported by staff, is made available to service users and their families. The procedure was noted to advise complainants that the CSCI would only investigate complaints after the home’s internal procedures had been used. This was amended by a member of staff during the inspection to confirm that the CSCI could be approached at any time that the complainant wished to do so. The home maintains a log of complaints received. Scrutiny of the complaints log showed that one complaint had been investigated since the last inspection and that the service user was happy with the outcome of the investigation. Service users spoke to the inspector about their understanding of the complaints procedure and confirmed that they would approach the manager, staff or their Social Worker if they wished to make a complaint. The home’s written procedures for responding to issues of adult protection have not been reviewed since the last inspections in January and May 2005, when requirements were made that this take place. It was of concern to note that the policy document stated that it had been reviewed in April 2005, however the procedure was seen to be the same as at previous inspections. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 15 Sampling of staff records showed that training in adult protection has not been provided for all staff. This is of particular relevance in light of the lack of review of the home’s adult protection procedures. In one individual plan sampled, it was recorded that the service user sometimes behaved in a physically challenging manner. There was no evidence of a strategy to manage this behaviour or proactive strategy to reduce the risk of the behaviour taking place. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29, 30 There are a number of repairs and maintenance issues that require attention to provide a safer and more comfortable environment for service users. Some specialist equipment that is required by service users has been broken and not replaced, which has an impact on their health and safety. EVIDENCE: The home was seen to be warm and free from unpleasant odour on the date of inspection. There were however a number of areas that require attention: * Cigarette burns were seen in the carpet in bedroom 7 and the designated smoking room, * Pull cords that enable service users to summon staff assistance from bathrooms were noted to be out of reach, * The bedding in one bedroom was dirty and stained, * The arm of the sofa in the designated smoking room was broken, Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 17 * No fly screens were in place on the kitchen windows, * A lock on the bathroom door on the second floor was broken, * Handwritten labels were seen on service users wardrobes and drawers, with no evidence that they were in place for the benefit of the individual. In one bedroom, a piece of equipment in place to enable a deaf service user to be alerted to the fire alarm was noted to be broken. This was of particular concern as the service user was reported to be a smoker who frequently smoked in his bedroom. Immediate requirements were made that this be addressed during the inspection. The home’s laundry room is situated away from areas where food is stored, prepared and eaten. Industrial type washing machines and dryers were noted to be in place. There are facilities for sluicing soiled linen and for staff to wash their hands after completing laundry tasks. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Staff have knowledge of service users cultural and spiritual needs and in the main can communicate with service users in their first language, which enhances the quality of life for the majority of people living in the home. The home’s recruitment and selection procedures are poor and do not protect the service users living there. Staff training records are not well maintained and some training has not been provided to enable staff to work effectively with service users. EVIDENCE: The majority of service users living at Park Avenue do not speak English as a first language. Observation of staff working with service users during this inspection showed that there are people available to communicate with service users in their first languages, with the exception of a deaf service user who has part time support from a deaf member of staff. The acting manager and staff member commented that it was possible for the team to communicate with the service user as they had learned some sign language, however it is a recommendation of this inspection that the home consider either staff training in British Sign Language (BSL) or the employment of more staff who can communicate using BSL. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 19 The staff team at the home demonstrated effective knowledge and understanding of service users cultural and religious needs. Service users spoke about a party that was being planned to celebrate Eid and others spoke about making regular visits to local Mosques and Temples in accordance with their religious beliefs. A Community Psychiatric Nurse, present for part of the inspection made positive comments about the staff team and said that they took a professional approach to working with her when she visited her clients at the home. Comment cards were issued by the CSCI to health care professionals that have contact with the home and the following comments received: “I have high regard for the professional way I am received when at the home”. “A very caring home”. “I am satisfied with the service provision”. Staff recruitment records were sampled and found to be undeveloped since the last inspection. Therefore the requirement made at the inspection on 16/05/05 is repeated. Records of staff training and development were sampled and found to contain some gaps in mandatory training and that which is relevant to the assessed needs of people living in the home. The quality of training in fire safety awareness gave the inspector cause for concern, which is further detailed in Standard 42 of this report. Staff had not received training in adult protection, which is outstanding from the previous inspection. Immediate requirements were made that the home send a copy of the current staff training matrix to the CSCI as a result of this inspection. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 There is no registered manager at the home. The acting manager has taken some action to meet requirements made at previous inspections, however some remain outstanding, which has an impact on the health and safety of service users living at the home. EVIDENCE: The registered manager has recently left his employment at the home and the acting manager has not made an application for registration to the CSCI. This was discussed at this inspection and the acting manager made assurances that she would submit an application to the CSCI upon receipt of an application form. A number of requirements made at the previous inspection had not been met, which are detailed in the statutory requirements section of this report. It was of serious concern that the home’s fire evacuation procedure stated that service users with a physical disability should be transported downstairs by use of a bed sheet, carried by four members of staff during “extreme emergencies”. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 21 This was reported by a member of staff to have been the advice of the facilitator of fire safety training provided to the staff team within the last two months. The inspector contacted an officer from West Midlands Fire Service (WMFS) during the inspection to seek further advice and was informed that under no circumstances should this practice take place. The WMFS officer confirmed that he would be visiting the home to address the matter within 2 weeks of this inspection. The acting manager confirmed that she would amend the home’s fire evacuation procedure to reflect this advice. A number of fire doors were seen to be wedged open at this inspection. This compromises the safety of all people within the home and immediate requirements were made that this practice cease with immediate effect. It was noted that a number of service users smoke in their bedrooms. Risk assessments were seen to be in place to identify controls to minimise the risks associated with this. However although risk assessments stated that metal bins were provided for service users to dispose of their cigarettes, a number were seen to have been fitted with plastic liners that could ignite if smoking materials were deposited in them. Immediate requirements were made that all bin liners be removed. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 3 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 1 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park Avenue, 17 Score 3 2 X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 1 X DS0000016854.V256728.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14(1-2) Requirement Timescale for action 01/02/06 2 YA9YA6 15(1-2) 3 YA9YA6 15(1-2) 13(4)(b,c) 4 YA23YA9YA6 15(1-2) 13(4)b,c 13(6) The home must develop a written procedure for the assessment of potential service users prior to their admission to ensure that the services and facilities within the home meet service users assessed needs. A pressure relief care plan 28/12/05 and risk assessment must be developed and implemented for the service user at risk of pressure sores. The plan must clearly state how support is provided at night. The care plan and risk 17/11/05 assessment for the service user who does not go out without supervision must be reviewed to ensure that it is relevant to his assessed needs and care practice must reflect the outcome of the assessment. The care plan and risk 17/11/05 assessment for the service user who demonstrates challenging behaviour must be reviewed to instruct staff how to manage the DS0000016854.V256728.R01.S.doc Version 5.0 Page 24 Park Avenue, 17 behaviour. 5 YA19 15(1-2) Care plans that identify service users health care needs must include information about how to respond to falls, mental health care and any other health care needs. The adult protection policy must be reviewed to ensure that staff do not investigate allegations of adult abuse unless directed by the lead agency, Birmingham Social Services Department. Staff must be briefed with regard to their role within the procedure. Staff must receive training in adult protection. The home must take action to address the following matters- repair or replace carpets burned by cigarettes, - make pull cords in bathrooms accessible, - provide clean bedding to all service users, - repair the sofa in the smoke room, - install fly screens over the kitchen windows, - repair or replace the broken lock on the second floor bathroom door, - remove handwritten labels on service users furniture, unless they are for their benefit. The home must ensure that suitable equipment is provided for service users to be alerted to the fire alarm. Staff recruitment records must be maintained in accordance with the Care Homes Regulations (2001). DS0000016854.V256728.R01.S.doc 28/12/05 6 YA23 13(6) 28/12/05 7 8 YA23 YA30YA24 13(6) 18(1)(c)(i) 23(2)(c, d) 15/01/06 28/12/05 9 YA29 23(4)(c)(ii) 17/11/05 10 YA34 7,9,19Sch2 17,2Sc4 6 28/12/05 Park Avenue, 17 Version 5.0 Page 25 11 YA34 7, 9, 19 Sch2(5) 12 13 14 YA35 YA37 YA42 15 16 YA42 YA42 The application form for new staff must include space for recording the names and contact details of two references. 18(1)(a)(c)(ii) A copy of the staff training matrix must be sent to the CSCI. 8, 9 The acting manager must submit an application for registration to the CSCI. 23(4)(c)(iii) The evacuation procedure in the event of fire must be amended to remove the instruction to transport disabled service users by use of bed sheets. The home must take action in response to any recommendations made by WMFS after this visit has taken place. 23(4)(c)(i) The practice of wedging open fire doors must cease. 23(4)(a) Plastic bin liners must be removed from bedroom bins. 28/12/05 17/11/05 27/01/06 10/11/05 10/11/05 10/11/05 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 YA32 Good Practice Recommendations Consideration should be given to the appointment of staff that can communicate using BSL and staff training in this area. Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Park Avenue, 17 DS0000016854.V256728.R01.S.doc Version 5.0 Page 27 - 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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