Inspection on 16/05/05 for 17 Park Avenue

This inspection was carried out on 16th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

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 10/11/05

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 Park Avenue Hockley Birmingham B18 5ND Lead Inspector Julie Preston Unannounced 16th May 2005 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 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 Stationary 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 E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Park Avenue Address 17 Park Avenue, Hockley, Birmingham B18 5ND Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 523 3712 Park Avenue Limited Mohammed Anwar Care Home 22 Category(ies) of Mental Disorder (22) registration, with number of places Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 21st January 2005 Brief Description of the Service: 17 Park Avenue is a large Victorian style building which is registered to provide care to 22 adults with mental health problems. The home is situated close to the busy Soho Road where a range of shops, places of worship and transport services are located. The homes staff speak a range of Asian languages that are appropriate to the needs of the people living there. Bedrooms are provided on all floors of the home and there is a passenger lift available. There is ramped access to the front of the building and car parking space at the rear. There are two lounges on the ground floor, one of which is a designated smoking area. The home has a number of shared bedrooms. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors over five hours and involved time spent talking to service users and staff, looking at care plans and risk assessments that describe how service users are cared for, a tour of the premises and sampling the records about the recruitment of staff that work in the home. An interpreter was present for some of the inspection so that the views of service users could be understood and included in this report. The home received a statutory requirement notice in February 2005 following the identification of serious concerns about the processes of individual care planning and risk assessment at the last inspection on 24/1/05. All requirements made by the CSCI within the notice had been met at this inspection, although concerns remain about the lack of comprehensive detail provided within care plans and risk assessments, which is necessary to ensure service users needs are identified, recorded and met. The home received a letter of serious concern in March 2005 from the CSCI’s pharmacist inspector following concerns about poor medicines management. All requirements made by the CSCI in relation to medication had been met at this inspection. What the service does well: What has improved since the last inspection? The way in which the home plan the care of the people who live there has improved so that more information is made available to staff about the needs of individual service users. There is more work to be done in this area, which was discussed with the home’s manager at the inspection and is recorded in Standards 6-10 of this report. The home has fitted new carpets in the hallways and cleaned some bedroom carpets, as this was required at the last inspection. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 6 A new floor has been laid in the laundry, which makes the cleaning of this room much easier. Robust systems have been installed and implemented resulting in an improved and safe system of medicine management. 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. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 standard(s) x None of these standards were assessed at this inspection. EVIDENCE: Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 standard(s) 6, 9 Progress has been made by the home to develop the format of individual care planning linked to a system of risk assessment in order to instruct staff about the manner in which they provide support to service users in accordance with their assessed needs. Individual plans and risk assessments are not completed in sufficient detail to enable the reader to determine how to meet service users needs. EVIDENCE: Each service user has a plan of their care needs and those sampled showed that some development has taken place since the last inspection. All plans sampled had been reviewed within the last three months and a new format has been introduced that links the assessed needs of the individual with a process of risk assessment which identifies methods of control to manage recorded areas of risk. Two of the plans seen were not completed in full and showed limited information about the purpose of night time checks by staff, which were recorded as being necessary every hour. A senior member of staff said that night time checks of each floor of the home were made by night staff, this being recorded as a tick against each service users name every night. There was no further information within care plans about the rationale of making Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 10 hourly checks on service users during the night or whether this related to individual concerns about service users. The care plans sampled showed that the home has made some progress in identifying individual’s needs, however development is needed to ensure that they are completed in sufficient detail as to enable the reader how to meet individual needs. For example, a care plan stated that a service user with diabetes must follow a specific diet but would ignore dietary advice regularly. There was no information instructing staff how to respond to this issue or any records of the food consumed by the person to enable staff to judge whether a suitable diet was being offered. Risk assessments for service users that smoke in their bedrooms have been completed as this was identified as a matter of serious concern at the last inspection. No evidence was seen that soft furnishings were flame retardant, as stated in the risk assessments sampled and immediate requirements were made that this is confirmed to the Commission for Social Care Inspection (CSCI) within seven days of this inspection. A risk assessment was seen that related to an individual’s excessive consumption of alcohol, with methods of control identified as close observation and encouragement to reduce consumption. No further information was provided to instruct staff about acceptable levels of alcohol consumption, interaction with any prescribed medication or support from other agencies with experience of alcohol misuse. It was not possible to establish that the risk assessment related to the individual’s current needs, as it was not dated, however a member of staff confirmed that it was relevant. A number of other risk assessments were seen to be undated, which does not enable anyone reading them to judge whether they relate to service users current needs and does not assist in the process of their regular review. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 standard(s) 13, 14, 15, 16, 17 The home does not provide sufficient leisure or community based activities that reflect the expressed wishes of service users, which influences the quality of their lifestyles. Service users are not consulted about the timing of meals and there are limited opportunities for service users to prepare and cook their own food, which may affect their enjoyment of mealtimes. The home does not promote service users rights to privacy, as bedroom door keys are not provided. Service users are supported to maintain contact with their families and friends. EVIDENCE: A list of activities attached to the home’s rota showed that an activity is recorded for each day of the week, for example sports and cinema. On Saturdays and Sundays there are no recorded activities; the list states the days to be for “rest”. Service users care plans gave little information about their preferred leisure interests and the daily records sampled did not reflect those activities listed with the rota. It was apparent from this evidence and service users comments that they have not been consulted about the provision of leisure opportunities within the home. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 12 One service user said that she did nothing in the home except to watch television and another said she went out only once a week. Two service users said they played board games in the home, but otherwise had nothing to do. Three service users said they would like to go out more and one said she visited her local temple on a regular basis. The front door of the home is kept locked and service users have to ask for it to be unlocked if they wish to go outside. A policy refers to the locking of the front door as necessary to prevent vulnerable people from leaving the building, however states that some service users may have a key if this is assessed as being safe. One service user confirmed that he had a key to the front door. Of the five service users that were asked, none had a key to their bedroom door. This matter must be addressed by the home to protect the privacy of the people living there. The home has a visitors policy which staff confirmed is made available to service users and their friends and relatives. During this inspection some service users were visited by their relatives and others spoke about having regular contact with relatives, including the opportunity to invite them for meals at the home. Service users said that they had few opportunities to prepare and cook their own meals at the home, despite their wish to do so. Two service users said that they would prefer more meat in the range of food offered as choices were often vegetarian. Comments were made that mealtimes are often very early, for example lunch was being served at 11.30am during this visit. Immediate requirements were made that service users are consulted about the arrangements for mealtimes within the home. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 standard(s) 20 Clear comprehensive arrangements have been installed to ensure the service users medication needs are met. EVIDENCE: The pharmacist inspector from the CSCI visited the home on 18/5/05 and made the following comments: “Staff and the manager have worked hard to install robust systems for medicine management within the home following a letter of serious concern regarding previous poor practice from the pharmacist inspector. All staff have received detailed training from the community pharmacy regarding good practice and individual drug education relative to the homes medication use. All audits undertaken were correct. The manager was keen to implement further good practice. Written protocols supported occasional use drugs and medication reviews were regularly sought on a six monthly basis.” Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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 standard(s) 23 The home’s adult protection and care planning procedures are not robust and place service users at risk of harm. EVIDENCE: The home’s written procedures for responding to issues of adult protection have not been reviewed since the last inspection in January 2005, when requirements were made that this take place. Two staff members training records showed that they had received no training in adult protection or physical intervention. One care plan sampled stated that a service user demonstrates physical aggression to others and instructed staff to avoid contact during this time. This approach does not maintain the safety of the individual and could place others at an unacceptable level of risk. Another care plan described a service user as demonstrating “inappropriate” sexual behaviour, with no other information to describe how this opinion had been arrived at and whether other people would be at risk as a result of the behaviour. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 24, 26, 28 The home’s programme of maintenance and repair does not demonstrate that broken equipment is identified then replaced or repaired, which creates an unsafe environment for some service users. The communal space in the dining room is insufficient for the number of people living at the home. Progress has been made to provide a designated smoking room, which ensures that non-smokers have a smoke free area in which to spend their time. EVIDENCE: The home was warm and free from unpleasant odour at this inspection. A number of areas within the home were in need of cleaning. Dirty extractor fans were seen in the kitchen and bathroom, bedroom carpets were dirty and the bedding in several bedrooms was dirty and stained. Immediate requirements were made that replacement bedding is provided for service users. A number of cigarette burn marks were seen on mattresses and bedroom carpets, which is of concern as there was no evidence that soft furnishings had been made flame retardant. Some broken furniture was seen in bedrooms; • Broken chair and radiator cover in room 7 • Broken bedside cabinet in room 5 Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 16 • Broken radiator cover in room 10 • Damaged safety rails in room 15 There are shared bedrooms at the home, two of which were looked at during the visit. Neither room had any screening to enable the people sharing bedrooms to maintain their privacy. A designated smoking room has been created away from the main lounge since the last inspection and positive comments were made by service users about this facility. One non-smoker said she liked sitting in the lounge now that the smell of cigarette smoke was gone. The dining room at the home is small and does not provide sufficient space for service users to take their meals together. There is not enough seating for the number of people living in the home. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 The home’s recruitment and selection procedures are poor and do not protect the service users living there. Staff have knowledge of service users cultural and spiritual needs and can communicate with service users in their first language, which enhances the quality of life for people living in the home. EVIDENCE: The recruitment and selection records for two members of staff were looked at during this visit. The application form completed by a member of staff who had been employed within the last four weeks did not contain a space for references to be recorded and the one reference on file was addressed “to whom it may concern”. No dates of previous employment or information about previous experience had been recorded on the application form and there was no evidence that any of these matters had been followed up by the home. The home’s rota showed that one member of staff is working in excess of the hours permitted by the Home Office, which remains the same as at the previous inspection. Staff at the home demonstrate that they are able to communicate with service users in their first language and those staff spoken to during the visit clearly understood the cultural and spiritual needs of the people that live there. Two service users described staff as “friendly” and “very good carers” and another said she thought the staff “did a very good job of looking after her”. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 18 A member of staff is employed to work on a part time basis with a service user that has a hearing impairment, however the rota did not record this person’s shifts within the home. The registered manager was unable to confirm the number of staff who have achieved training at NVQ Level II or above, but advised that this information would be sent to the CSCI by 31/5/05. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The home is failing to protect service users from the risk of injury due to poor fire safety procedures. Poor food storage practice creates an unacceptable level of risk to service users health. EVIDENCE: The home’s fire safety records showed that the fire alarm system had been tested on a regular basis and that an annual service had taken place. Examination of the fire evacuation procedure identified that no information is included about how to move individual service users and in particular a service user that cannot hear the fire alarm. It was of concern that the fire risk assessments in place for service users that smoke in their bedrooms stated that flame retardant furnishings are provided, however this was not in evidence at this visit. The number of cigarette burns on bedding and carpets demonstrate that smoking takes place throughout the home. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 20 A loose electrical socket in the “ladies bathroom” was seen on the wall, which places service users at risk of injury. The door lock in this bathroom was not secure and needs to be repaired. The home’s kitchen does not contain a fridge. A fridge is located in the cellar where the majority of food is stored, however this is a considerable distance from the kitchen. At this visit mayonnaise, milk, margarine and ketchup was being stored in the kitchen, which poses an unacceptable food hygiene risk. Immediate requirements were made that a fridge is provided in or close to the kitchen. Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 x 2 x x Standard No 11 12 13 14 15 16 17 x x 1 1 3 2 2 Standard No 31 32 33 34 35 36 Score x 2 x 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Park Avenue Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 1 x E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 22 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 6 Regulation 15(1)(2)( a-d) Requirement Timescale for action Within 4 weeks and ongoing 2. 6, 9 3. 9, 42 4. 9 5. 13, 14 Each service user must have a written plan of care that sets out how their needs in respect of their health and welfare are to be met. Individual plans must be subject to regular review. 15(1)(2)( Night time checks on service a-d) users must be made only in accordance with written protocol and/or risk assessment and in response to the individuals assessed needs. 13(4)(a-c) Flame retardant bedding and 23(4)(c)(v furnishings must be provided in ) the bedrooms of all service users that smoke. 13(4)(a-c) Risk assessments must be completed for all service users in accordance with their assessed needs and the controls in place to manage identified hazards must be clearly stated. Risk assessments must be dated and subject to a process of regular review. 16(2)(mService users must be consulted n) about the leisure activities provided within the home and their preferences about accessing community based activities. Reasonable steps must E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Within 1 week and ongoing Within 1 week Within 1 week and ongoing Within 4 weeks and ongoing Park Avenue Version 1.30 Page 23 6. 16 7. 17 8. 17 9. 6 10. 9 11. 23, 6 12. 23 be taken to ensure that suitable activities are provided. 12(4)(a) Service users must be offered a key to their bedroom door unless the reasons for not doing so are clearly recorded within the individual plan. 16(2)(i) Service users must be consulted about the timing of meals and arrangements made to adjust mealtimes according to their preferences. 16(2)(h) The home must make arrangements for service users to prepare and cook their own food, should they choose to do so. 15(1)(2)( Records of food must be a-d) maintained for service users following specific diets to enable staff to determine that an appropriate diet is provided. 13(4)(b-c) The risk assessment for 12(1)(aexcessive consumption of alcohol b) must be updated to include information about acceptable levels of consumption and any contraindications with prescribed medicines. A referral to an agency with experience of alcohol misuse must be made according to the outcome of the assessment. 13(6) Written protocols for the 18(1)(a) management of service users challenging behaviour, including sexual behaviour must be developed and implemented. Staff must be provided with training appropriate to the level of intervention required. 13(6) The adult protection policy and procedures must be updated to ensure that there is a procedure in place for physical intervention, which is in keeping with professional standards and guidance. E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Within 4 weeks Within 2 weeks Within 4 weeks Within 1 week and ongoing Within 1 week Within 1 week Within 4 weeks Park Avenue Version 1.30 Page 24 13. 14. 15. 16. 17. 23 24 26 26 26, 42 13(6) 18(1)(a)(c ) 23(2)(d) 23(2)(d) 16(2)(c) Training in adult protection and physical intervention must be provided for all staff. Dirty extractor fans in the bathrooms and kitchen must be cleaned. Bedroom carpets must be cleaned. Within 8 weeks Within 1 week and ongoing Within 1 week and ongoing Within 1 week Within 4 weeks 18. 26 19. 20. 21. 26 28 32 22. 23. 32 34 24. 34 25. 34 All dirty and worn bedding must be replaced. 13(4)(a-c) The registered manager must 23(4)(c)(v advise the CSCI, in writing of the ) steps that will be taken to review fire precautions following the observation of cigarette burns in furniture and carpets in the home. 16(2)(c) The following items must be 23(2)(c) repaired or replaced: room 7 broken chair and radiator cover, room 5 - broken bedside cabinet, room 10 - broken radiator cover, room 15 - damaged safety rails. 16(2)(c) Screening must be provided in shared bedrooms following consultation with service users. 23(2)(g) Sufficient seating must be provided in the dining room for service users to take their meals. 18(1)(a) The registered manager must advise the CSCI of the number of staff that are qualified to NVQ Level II or above. 17(2) The rota must include the names Schedule and shifts of all staff working in 4(7) the home. 7, 9, 19 Staff recruitment records must Schedule be maintained in accordance 2 & 17(2) with the Care Homes Regulations Schedule (2001). 4(6) 7, 9, 19 The application form for new Schedule staff must include space for 2(5) recording the names and contact details of two references. 17(2) The registered manager must Schedule advise the CSCI, in writing of the E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Within 1 week Within 2 weeks Within 2 weeks By 31/5/05 Within 1 week and ongoing Within 1 week and ongoing Within 1 week Within 4 weeks Page 25 Park Avenue Version 1.30 4(6)(f) 26. 42 27. 28. 42 42 reasons for the member of staff with Home Office limitations on the hours worked, working in excess of those hours for the periods 18 - 24/4/05 and 2 8/5/05 and confirm the arrangements in place to ensure that these conditions are not breached. 23(4)(c)(ii The fire evacuation procedure i) must be amended to include information about how to move individual service users. Staff must be made aware of their role within this process. 13(4)(a-c) The loose electrical socket in the ladies bathroom must be made safe. 16(2)(g) A fridge must be provided in or close to the kitchen. Within 2 weeks Within 1 week Within 1 week 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 Good Practice Recommendations Park Avenue E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local 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 E54_S16854_ParkAvenue_V227553_160505 Stage 4.doc Version 1.30 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. 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!