Inspection on 23/11/07 for 17 Park Avenue

This inspection was carried out on 23rd November 2007.

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 7 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 26/01/07

17 Park Avenue 25/05/06

17 Park Avenue 10/11/05

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 Unannounced Inspection 23 November 2007 09:00 rd Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 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) faisalazam@london.com Park Avenue Limited vacant post Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Residents must be aged under 65 years with a mental disorder Staff at the home do not administer insulin, and healthcare professionals are contacted to provide this support where service users 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. Three named service users over 65 years with a mental disorder can be accommodated whilst their needs can be met at the home. 26th January 2007 4. 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 people with a physical disability to shower and bathe. There is a well established team of staff, some of whom have worked in the home for many years. Information is shared with people who live at the home during house meetings and there are leaflets describing how to make complaints available in the entrance hall. Many service users do not speak English as a first language. The staff team have the skills collectively to communicate with people in their first languages. Fees charged to service users range from £276.70 to £5140.80 a week, to which individuals pay a set amount from their Department of Works and Pensions benefit. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. Three service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. Individuals’ culture and religion are well understood so that people live a lifestyle that meets their needs. There are good procedures to listen to people and keep them safe from possible harm. Staff that work at the home are checked to make sure they are suitable to work with vulnerable people for the protection of the people who live there. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 6 Staff know people who live in the home well and are friendly to them. People said, “They are good, they listen”. “I like the staff. I am very happy”. “The carers always listen”. “I can talk to staff if I’m unhappy or have a problem”. What has improved since the last inspection? What they could do better: An urgent letter was sent to the home after this visit as the way some people’s medication had been managed could place them at risk of harm. An answer was received by the inspector to say that the matter had been addressed within two days of the visit. Some records that describe how people should be cared for so that they stay safe and well are not well written. They need to improve so that people who live in the home get the care they need. Staff do not always write down what people have done each day and it seems that sometimes people are not taking part in many activities. Records about peoples’ medicines need to be filled in properly to make sure that people have their medicine when they need it and that it is looked after safely. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 8 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.V350963.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: The home has a statement of purpose and service user guide, which is made available to people who live there and their relatives. A representative of the registered provider confirmed that the statement of purpose and service user guide were due to be reviewed so that they would be more accessible to people who live in the home. There have been no new admissions since the last inspection although there are currently some vacancies. There are systems in place to ensure that individuals’ needs are assessed before they move into the home and that people have an opportunity to visit and stay over prior to making any decisions about whether to move in. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 10 Three people spoken to during this fieldwork confirmed that they had received opportunities to visit the home on several occasions to assist them to decide whether to move in. One person said, “I think this is the best place for me”. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans and risk assessments that describe how to support people have not always been reviewed which could lead to inconsistent care practice and individuals needs not being met. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: The care plans for three people were sampled. Each contained some clear information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. Some care plans were unsigned and undated and it was difficult to establish that the information was relevant to peoples’ current needs. In one case, the Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 12 description of support needed by a person to manage their finances was reported by staff to be out of date, despite being maintained in their plan of care. This could lead to different approaches to care practice, which is not consistent for the people who live in the home. One person’s care plan dated 2005 had not been reviewed, although staff did confirm that it had been replaced by an up to date plan, which was observed. It is necessary that the content of care plans be reviewed so that accurate information about the support people require meeting their needs is made readily available for the staff team who care for them. The home completes risk assessments for people so that consideration is given to supporting them to take responsible risks and promote their independence. The risk assessments sampled for the three people “case tracked” were generally clearly written, identifying how to minimise hazards so that their health and safety could be promoted. In one case a person had been identified as being at risk of falls, although no moving and handling risk assessment had been completed in response to this observation so that hazards could be minimised to promote the person’s safety. In another case, a person had harmed a member of staff however; no review of the person’s care plan and risk assessment had been conducted to reflect how staff should respond to safeguard themselves and the person demonstrating the behaviour. Further development of risk assessment systems is needed to make sure that the health and well being of people who live in the home is promoted and protected. People who live at Park Avenue have regular house meetings to discuss events within the home and to plan day trips and activities. One person said, “We had a party for Eid. It was good”. Records observed described how staff had responded to peoples’ suggestions, which indicates that choices and decisions are being listened to and respected. Comments were received from people who live in the home with regard to the choices and decisions they make“I decide what I do”. “I chose how I have my room”. “Every day you choose your food”. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 13 Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at the home would benefit from the range of activities available being developed so that they experience a more meaningful lifestyle. People are supported to maintain relationships that are important to them. The people living in the home are offered a range of nutritious meals that meet their cultural needs and preferences. EVIDENCE: Care plans sampled did identify peoples’ preferences with regard to they activities they take part in and how they like to spend their time. Some people who live at Park Avenue made positive comments about the opportunities they have to go out and do things they enjoy. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 15 “I go to Gudwara every day. Very important”. “I like to go shopping and for walks. I go a lot”. “I always go to the Mosque”. Others said that they spent a lot of their time in the home and did not go out very often. The daily records for three people were sampled. One person (who confirmed this) had clearly been out frequently and enjoyed each experience. Two people’s records contained several blank spaces, no outdoor activities for a period of eleven days and descriptions of “1:1 with staff”, with no explanation about what this meant. It was not evident from discussion with staff and observation of peoples’ daily records that people who live in the home are being adequately supported to pursue their preferred activities and spend time away from the home doing so. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about the support people need to keep in touch with those that are important to them, such as making telephone calls, receiving visitors and inviting friends and relatives to cultural celebrations and parties. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered, including vegetarian and Halal meals, which is reflective of people’s cultural needs. There was evidence in house meeting records that people who live in the home had been consulted on a regular basis about the content of menus. People said, “The food is good, we have a choice” and “There are always many things to choose from”. Some people require specific diets to maintain good health. Catering staff were able to provide records that guidance had been followed so that people were not placed at risk of becoming unwell. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health care records do not clearly state how to support individuals to maintain good health, which could lead to people’s needs not being met by the staff team. Medicines management is not always robust, which could lead to peoples’ needs not being met. EVIDENCE: Three personal and health care plans were sampled at this visit. There was some good information about peoples’ personal care needs and preferences, which staff clearly understood so that people receive care in a manner they need and like. Staff demonstrate effective knowledge of peoples’ cultural needs; same gender personal care is offered and care routines are flexible so that they are reflective of the timing of religious services. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 17 The registered provider has recently appointed a Psychiatric Nurse Specialist and Occupational Therapist as part of a drive to improve health care outcomes for people who live at Park Avenue. The inspector spoke to both members of staff during this visit and was advised that they have received a briefing for the work they are to undertake, although were still a stage of assessing priorities as they had only been in post for a few weeks. The health care records sampled varied with regard to detail. Some described clearly how to support people to maintain good health and listed regular contact with health care professionals and the outcome of the contact. One person’s records did not detail any contact with health care professionals since September 2006 and the person had missed a cardiology appointment in September 2007. There was no explanation of why this had occurred, although staff did state that this might be an administrative error. Another person, who had a pressure wound treated in November 2007, did not have a pressure care plan and there was no information within the healthcare plan to instruct staff how to position the person to reduce the risk of further pressure wounds. This person’s healthcare plan further identified a need for annual dental appointments and six weekly chiropody treatments. The last entries within the records available described dental treatment in September 2007 and chiropody in October 2006. Staff were unable to explain why more frequent appointments had not taken place. This clearly does not evidence that the person’s needs are being fully met. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medication was observed to be securely stored in a locked cabinet and it was considered positive that some staff had received training in the safe handling of medicines to further safeguard service users health and well being. Where people are prescribed medication on an “as required” basis, written protocols were in place to guide staff as to when they should be given. Staff spoken to were able to describe the circumstances under which the medication of “case tracked” people should be given. A number of errors were, however observed. The midday medication administered to people on the date of this visit had not been signed for by the staff member responsible for dispensing it on the medication record. The records for a person with diabetes showed blood sugar readings that indicated a need for action to maintain the person’s health. There was no Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 18 information to describe any action taken. It was explained by staff that action had been taken, but not recorded. The same person’s records stated that Dextrose should be given if a low blood sugar reading occurred. There was no information on the medication administration record to support this statement and no Dextrose available in the medication cabinet. A code letter had been entered onto a person’s medication record, which had not been explained in writing on the reverse of the record where there is space to do so. It was not clear what the code letter referred to. It is recommended that if codes are used, they be justified with a written description on the record for the purposes of clarity. Three people’s medication had been stored in cassettes, rather than in the original packaging so that it was unclear what each cassette contained. An immediate requirements form was left at the home so that this matter could be investigated and rectified to ensure that people receive their medicines in a safer manner. Some good practice had taken place. A sample signature list of staff responsible for giving out medication formed part of the home’s procedures so that any errors could be audited and traced back to specific staff members. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: The home has a complaints procedure that is available for people in the entrance hall. The procedure has been translated into the first languages of people who live at Park Avenue. From discussion with people and written feedback from some who live at the home it was evident that they were aware of their right to raise concerns and complaints and that they were confident they would be listened to by the staff team. Since the last visit to the home an issue had been referred to Birmingham Social Care and Health under adult protection procedures with regard to possible financial irregularities. The home had taken appropriate action to safeguard the vulnerable person and had informed the CSCI as is required under the Care Homes Regulations (2001). A representative of the registered provider confirmed that as a result of this referral, a new system to audit all financial records maintained for those who live in the home had been implemented and a financial director appointed to oversee audits as further safeguarding mechanisms. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 20 Staff spoken to during this visit confirmed that they had received training in adult protection. Observation of the home’s training matrix showed that 90 of the staff team had received this training and challenging behaviour training to assist them to meet peoples’ needs more effectively. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well furnished, warm and well decorated which provides a comfortable environment for the people who live there. EVIDENCE: 17 Park Avenue is situated off the Soho Road area of Hockley in Birmingham. The home is well placed for access to local amenities such as places of worship, public transport routes, shops, cafes and restaurants. This is important for the people who live there as they enjoy accessing community based activities. A tour of the building was completed at this visit. The home had been maintained to a good standard and was clean, tidy and hygienic. Satisfactory hand washing facilities were observed in the kitchen, laundry room and bathrooms, which should reduce risks of the spread of infection within the premises. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 22 Since the last visit new carpet had been fitted in the lounge and laminate flooring throughout the ground floor. The premises had been redecorated from top to bottom, with new furniture in the dining room. Several people who live at Park Avenue were pleased to report they had chosen new bedroom furniture and bed linen. These improvements create a pleasant environment for people to live in. There are a range of toilets and assisted bathing facilities located throughout the home for ease of access for those living there with a physical disability. People who live at Park Avenue said, “It’s always nice and clean”. “Spotless”. “Always clean”. Two members of staff have been recruited with specific responsibility for cleaning the premises. It was felt by staff that this improved the presentation of the building, as previously care staff had had to perform cleaning duties alongside their role as carers. The registered provider commented in the AQAA that the garden area needed to be improved for the benefit of the people who live in the home. It was reported that there are plans to commence this work after the winter. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the ongoing protection of the people who live there. EVIDENCE: At this visit staff were observed to interact well with people who live at the home and have clearly formed good relationships with them. The inspector was told, “They are good, they listen”. “I like the staff. I am very happy”. “The carers always listen”. “I can talk to staff if I’m unhappy or have a problem”. The home’s rota for a two-week period was observed. Three waking night staff are employed who work from 9pm until 9am the following morning. The new manager stated that she is planning to introduce portable phones for staff to communicate with each other overnight so that they can summon assistance from each other in the event of an emergency. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 24 The manager confirmed that she felt staffing levels during the day and night to be appropriate for the number and needs of people living in the home and explained that designated staff are on duty each day to offer 1:1 support to people who need it. This was seen in practice during this visit. Examination of the staff training matrix showed that staff complete mandatory health and safety training on a regular basis to assist them to meet people’s needs. Some specific training such as managing challenging behaviour, diabetes care and British Sign Language had been provided, which is reflective of the needs of the people who live in the home. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. The frequency of formal supervision had increased so that staff were meeting with a senior member of the team at least once every two months to review their role and responsibilities and identify any individual training needs to assist them to meet the needs of people who live in the home more effectively. It was positive to note that staff were using sign language to communicate with people with a hearing impairment. This is an improvement from the last visit, when only a few members of the staff team were able to sign to people. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well managed and peoples’ health and safety is promoted and protected. EVIDENCE: The home does not have a registered manager, although a new manager had been appointed prior to this visit. The new manager has completed her NVQ Level IV in care management and her Registered Manager Award, working in care services since 1990. The manager was present at this visit and talked about some of the things she had done to improve outcomes for people who live in the home such as Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 26 introducing a monthly health and safety check of the premises and coming in to work during the night to observe the practice of night care staff. The manager demonstrated commitment to driving further improvements within the home and confirmed that she would be submitting an application for registration as manager to the CSCI. Quality assurance systems are in place. House meetings occur every 4-6 weeks and people are encouraged to give their views about the way the home is run. Records showed that people had discussed a range of topics such as menu and activity planning and the celebration of cultural events. A representative of the registered provider visits Park Avenue on a regular basis to comment on the standard of care provided, which contributes to the management of the home. Health and safety and cleansing audits also take place so that people who live in the home are protected by robust procedures and care practice. A new project team has been established consisting of the Chief Executive of Park Avenue Limited, a psychologist, the home’s manager, Financial Director, Registered Mental Nurse and a Compliance Manager to oversee quality assurance within the home. The inspector was shown a statement of purpose that identified how the project team plan to monitor quality standards and achieve compliance with the Care Homes Regulations (2001). It is anticipated by the Chief Executive Officer that the project team will identify areas of improvement necessary to enhance the lifestyle and standard of service received by people who live in the home. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Some of these were sampled. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. The home’s training matrix showed that 90 of the staff team had received fire safety training within the last twelve months. Hot water temperatures are checked each month to ensure that they do not pose a scalding risk to people. The passenger lift is serviced each year to make sure it is in good working order and safe for people to use. Staff have undertaken health and safety and infection control training, which should ensure a safer environment for the people who live in the home. Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 3 X Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 28 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 YA6 YA19 Regulation 15(1-2) Requirement Each person must have a plan of care that clearly describes how his or her assessed needs in respect of health and welfare are to be met. Care plans must be reviewed to ensure that they are relevant to peoples’ current needs. Not met from previous inspection on 26/1/07. 2 YA9 13(4)(c) Risk assessments must be completed and implemented for people where hazards to their health and well-being are identified so that they are not placed at unreasonable risk of harm. Risk assessments must be reviewed on a regular basis to ensure they are relevant to peoples’ current needs. Each person must have opportunities to take part in social and leisure activities DS0000016854.V350963.R01.S.doc Timescale for action 01/03/08 01/03/08 3 YA13 16(2)(m, n) 01/03/08 Park Avenue, 17 Version 5.2 Page 29 4 YA19 13(1)(b) 5 YA20 13(2) that meet their needs and preferences. Each person must have access 05/02/08 to health care professionals for treatment and advice in accordance with their individual needs. Medicines must be dispensed 25/11/07 robustly so that people receive their medication in a safe manner. Immediate requirement. 6 YA20 13(2) Written and agreed protocols for responding to peoples’ low blood sugar readings must contain accurate information about any medicines that are to be administered in response and such medicines made available for their ongoing health and well being. 05/02/08 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 2 Refer to Standard YA6 YA20 Good Practice Recommendations Care plans should be dated so that it is evident they are relevant to peoples’ current needs and to aid the process of regular review. Codes used on medication administration records should be justified with a written explanation of what the code refers to so that people receive their medication as prescribed and in a safe manner. The outcome of the steps taken in response to blood sugar readings that require action should be recorded in the person’s records so that their health is maintained and to aid health monitoring processes. 3 YA20 Park Avenue, 17 DS0000016854.V350963.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V350963.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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