Inspection on 25/05/06 for 17 Park Avenue

This inspection was carried out on 25th May 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 68 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 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 25th May 2006 10:00 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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.V294131.R02.S.doc Version 5.1 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.V294131.R02.S.doc Version 5.1 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 Post Vacant Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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. 10th November 2005 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.V294131.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was conducted by two inspectors over the course of one day. One inspector spent time talking to service users in their first language and took a tour of the premises. Medication storage and administration systems were examined as well as records relating to service users care and safety. The inspectors had a meal with service users in the dining room and observed staff working with them. The CSCI continues to have concerns about the management of this home and further visits will take place to measure progress against the requirements made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: This inspection identified numerous concerns with regard to health and safety practice, medicines management, staff training and recruitment, care planning and risk assessment processes and records management. In some cases, service users health care needs are not being met, care plans and risk assessments need to be developed and reviewed. Sometimes the way staff care for service users does not reflect what is written in their care plans. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 6 Parts of the building were dirty, some equipment did not work and some furniture was broken. Service users said that they did not always have opportunities to go out and do things they enjoy. There was not enough food on the premises for the number and needs of the people who live there. Service users who have problems swallowing had not been referred to health care professionals for further assessment. Staff have not received training to work effectively with service users or promote their health and safety. Medicines management is poor and does not ensure that service users receive their prescribed medication. The way the home makes checks of new staff employed does not protect service users living there. Significant improvement is needed to ensure that service users health and welfare is promoted and protected. 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.V294131.R02.S.doc Version 5.1 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.V294131.R02.S.doc Version 5.1 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, 3 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The homes own assessment procedures are in need of development to ensure that the services and facilities available meet the needs of potential and established service users. EVIDENCE: There have been no service users admitted to the home since the last inspection therefore the admission procedure could not be assessed in practice. Requirements made at the previous inspection to review and update the procedure for admission and assessment of potential service users had not been met. According to personal records, the home is currently accommodating three service users over the age of 65 years, which is not reflected in the conditions of registration. A variation to the conditions of registration is required to be submitted to the CSCI, along with supporting evidence that the home can continue to meet each person’s individual needs. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments do not clearly describe how service users needs are to be met. Care practice does not always reflect the guidance stated in care plans which has an impact upon service users needs being effectively met. EVIDENCE: Previous inspection reports have raised concerns regarding care plans and risk assessments lacking detail, not being clear about the care required by service users and not keeping plans and assessments under review. Since the last inspection, the home has implemented “basic care plans” which give a brief overview of service users individual needs. Whilst this is a positive development to providing basic information it remains of concern that care plans do not clearly and comprehensively identify individual’s needs. The four care plans sampled did not clearly define service users needs. One plan referred to a service user’s “aggression” but did not describe what this meant or how to reduce the risk of aggressive behaviour occurring or manage Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 10 incidents of aggression. Another plan identified a service user to have specific needs with regard to moving and handling, referring the reader to handling guidelines. These were not in place. It was of concern to note that requirements made at the previous inspection to devise and implement pressure relief plans and risk assessments for service users with needs in this area had not been met. Risk assessments were noted to be undated in two files, making it difficult to establish whether they were relevant to individuals current needs or had been reviewed. In some cases, care practice was not consistent with the information contained within care plans. For example, one plan referred to a service user to be at risk of choking and therefore needing supervision whilst eating. The service user was observed to eat his lunch with no support from staff. Another service user’s daily records described the person using the toilet without staff support, however the care plan stated a need for supervision due to an identified risk of falls. This practice could affect the health and safety of the persons concerned and must be reviewed. There is a need for staff to receive training in care planning and risk assessment in order to develop the team’s knowledge and skills base for the benefit of service users. Staff reported that service users attend house meetings on a regular basis and that records were in place of each meeting. Records were seen however they were dated 2004, which was inconsistent with the information provided. Two service users said they had not been invited to house meetings, but would like the opportunity to do so. Senior staff advised inspectors that service users manage their own money without support. A record was seen that showed service users sign for their weekly personal allowances. One exception was for a service user that had been admitted to hospital. The home must have systems in place to ensure that service users sign for monies given to them or that two members of staff sign the record in the event that the individual is unable to do so. At the last inspection it was considered positive that a deaf service user had been supported by a deaf member of staff to access community-based activities and take part in tasks around the home. It was therefore disappointing to note from the rota that the member of staff was only working twenty hours a week. There was no evidence to show that other staff had received training to communicate effectively with the service user in his first language. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for service users to take part in activities they enjoy. Service users are supported to keep in touch with their friends and relatives. Service users dietary needs are not well planned and food supplies were not available in sufficient amounts for the number of people living in the home. EVIDENCE: A range of photographs were seen that showed some service users taking part in activities such as cooking, swimming and craftwork. It was unfortunate that the photographs were kept in the basement office to which service users do not have access. Care plans sampled did not evidence that individuals’ social and leisure needs had been assessed. In some care plans a list of preferences had been completed however daily records did not verify that preferred activities had been offered to service users. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 12 For example, examination of one person’s daily records over a three-day period stated that he had “sat in the lounge”. There was no further information to describe whether any activities had been offered. The inspectors spoke to this service user who said he had an interest in cooking and would like to go for a walk every day, but had not had opportunities to do so. Another service user showed inspectors an activity planner in her bedroom but said she had not taken part in any of the activities planned for a while. This must be explored with service users and activities provided based on individual needs and preferences. Service users made positive comments about the support they receive to keep in touch with friends and relatives. The four people spoken to all confirmed that they were able to see their visitors in private and could invite them for a meal if they wished. Food supplies were observed to be poor and there was insufficient stock in place for the number and needs of people living in the home. Requirements were made that adequate supplies be purchased with immediate effect. The home does not keep records of the food consumed by service users. This was of particular concern due the number of people with diabetes in residence. One service user’s daily records stated that over a four-day period, he had been given only bread and milk, yoghurt, rice and Fortisip. Staff commented that this was due to the person having swallowing difficulties, however there was no evidence of referral to a dietician or Speech and Language Therapist for a dysphasia assessment. This is required. The inspectors had lunch with service users, which consisted of a choice of curries prepared during the morning, rice, salad, chapattis, pickles and vegetables. Service users made positive comments about the meals provided although some said they would like to have more English food such as fish and chips and go food shopping more often. Some service users commented on the timing of meals; lunch was served at 11.30am on the date of inspection, which was felt to be too soon after breakfast. The dining area in the home was noted to be crowded, with five tables and twenty chairs within a relatively small space. This is not sufficient for the number and needs of service users living in the home and must be reviewed. The inspectors observed staff attempting to manoeuvre a service user in a wheelchair through the dining room, which took a considerable amount of time, as there was little space to turn the wheelchair. It was noted that green paper towels, which felt harsh when used on the face, were provided in place of napkins or tissues. This must be reviewed. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Service users health care needs are not being fully met. Medicine management is not robust and places service users at risk of harm. EVIDENCE: The inspectors sampled personal and health care records for four service users. It was pleasing to note that some good recording had been made, such as reference to individual’s cultural needs and preferences within daily personal care routines. Staff were able to describe the support they gave to these service users which was consistent with the care plans in place. Service users were observed to be well dressed according to their age, gender and cultural preferences. The health care records of two service users were tracked. In both cases appointments had been entered within the records, however there was a lack of information to describe the reason for the appointment and the outcome. It was therefore not possible to establish that service users health care needs were being met. One service user’s records identified that he had not seen a dentist since 2003. This must be followed up by the home. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 14 Another record stated that an ambulance had been called in response to a service user complaining of pain all over her body. The report from the paramedics advised the home to contact the service user’s GP for a medication review. This had not been done. Waterlow risk assessments were seen, which identified service users to be at risk or high risk of pressure sores. There were no care plans in place to identify the action to be taken to reduce this risk. Medication storage and administration systems were examined. It was of concern to note that the 4pm medication was not administered on time and the inspectors reminded staff of the need to start. Several areas of poor practice were identified. Benzhexol prescribed for one service user was not available for administration on the date of inspection, as the medication had not been collected from the pharmacy. The service user had not received this medication during the evening of the previous day, as prescribed. Immediate requirements were made that the medication be collected and the reasons for this omission investigated. There was no written protocol for the administration of PRN (as required) Lactulose. A number of service users have diabetes and as a result staff record blood sugar levels on the MAR (medication administration record). A range of readings had been recorded however staff were vague about what constituted an acceptable level and could not satisfactorily describe the steps that would be taken if a reading was below or above this. Again immediate requirements were made that this be addressed. The inspectors observed medication to be kept in a fridge used for food storage. This is not appropriate and a separate fridge must be provided for medicines, with temperatures recorded whilst in use. A member of staff, who according to information provided by the home prior to this visit is employed as a driver, had signed the MAR on a number of occasions as having taken blood sugar levels. There was no evidence that this person had received training in the safe handling of medicines. Two service users MAR sheets stated that Lactulose and Lithium were “out of stock”. A senior member of staff commented that the Lactulose was no longer used however this was not consistent with the information on the record. The inspectors observed the home’s medication policy, which referred to the safe use of a medication trolley. The home does not have this facility therefore the policy must be amended to reflect actual practice. The inspectors were sent a copy of the home’s training matrix, which did not identify that any staff had received accredited training in the safe handling of medicines. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. There are systems in place for service users to make complaints about the service they receive. Adult protection systems need to improve to ensure service users are being protected from abuse and their welfare promoted. EVIDENCE: The inspectors were advised by staff and service users that the home has a complaints procedure. Five service users commented that they were aware of their right to make a complaint and would approach staff or their relatives to do so. The home’s complaints log showed that one complaint had been investigated using internal procedures within the last six months, concluding in a satisfactory outcome to the service user. The home has a copy of the Birmingham Multi Agency Adult Protection Guidelines. This report has identified that some care plans lack clarity with regard to managing aggressive behaviour from service users, which must be reviewed. The staff training matrix received by inspectors showed that only three staff had completed training in adult protection. This is outstanding from the last inspection. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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, 26, 30 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. Outstanding maintenance, repairs and poor cleansing routines has an impact on service users comfort and safety within the home. EVIDENCE: One inspector conducted a tour of the premises and made the following observations: Bathrooms, bath chairs and service users bedding were seen to be dirty and stained. In one case bed linen was observed to be stained with faeces, which is clearly not acceptable. Immediate requirements were made that this be addressed before the service user went to bed. Fluorescent tubes in the laundry room and lounge were not covered and there was no diffuser covering the light in bedroom 13. The cord to the wall light in bedroom 14 was broken and the lamps in bedroom 1 did not work. There is evidently a need to address the issue of lighting in communal areas and service users bedrooms as part of an ongoing maintenance programme. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 17 Broken handles were noted on the wardrobes and drawers in bedrooms 15 and 14. Bedroom 13 had been used to store another service user’s mobility scooter, which must be removed and stored securely. Damp patches were observed on the ceiling in bedroom 3 and the carpet in bedroom 10 was worn and dirty. Handwritten labels were seen on drawers and wardrobes, with no evidence that they were in place for service users benefit. This remains the same as at the last inspection. A number of service users commented that they did not have keys to their bedroom doors. Keys must be provided based on their individual needs and preferences. One toilet on the ground floor was out of order. This must be repaired. The pull cord for the emergency call system in the bathroom on the ground floor was not accessible to service users as it had been tied up out of reach. The shower chair in the shower room on the second floor was noted to be dirty and a number of bars of soap were observed. It could not be evidenced that the soap had been used by only one person, which creates an increased risk of cross infection. There were no paper towels for staff to dry their hands in the laundry room. All of these issues have an impact on service users comfort and safety within the home. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. A lack of training and poor recruitment and selection practice means that service users are not adequately supported and protected by the staff team. EVIDENCE: The inspectors requested that a training matrix be sent to the CSCI following this inspection, as the staff files sampled did not evidence that mandatory and service user specific training had been provided. The matrix was received within a week of this visit. It was of concern to note that four members of staff who were, according to the rota and pre inspection questionnaire, working in the home had not been included on the matrix. Training in moving and handling had been provided to only six members of staff within the last twelve months. This is urgently required as a number of service users need assistance to mobilise around the home. The matrix showed that of the six staff that work nights, none of them had received any training within the last twelve months. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 19 With the exception of the newly appointed manager no staff had received training in infection control or managing challenging behaviour. The majority of staff had not received training in adult protection, health and safety, fire safety awareness, basic food hygiene and first aid. One service user’s first language is BSL (British Sign Language). At the last inspection it was recommended that training in BSL be provided. No progress to consider this had been made. There is an urgent need to review the procedures for delivering staff training. This must incorporate mandatory training as well as sessions to meet service users individual needs, such as diabetes care and mental health awareness. The inspectors were concerned that a member of staff who was signed off sick came into the home and worked a shift, including giving out food and medication. This practice places the individual and service users at risk and is not acceptable. Recruitment records were sampled for the two members of staff most recently appointed to the home. In both cases no application form had been completed; no references were on file for one person and the other had submitted references “to whom it may concern” dated August 2005 and it could not be evidenced that they referred to the person’s employment at the home. No confirmation of a satisfactory CRB (Criminal Records Bureau) check had been received for either member of staff. The date that each person had begun work was unclear within the records seen. Again this is not acceptable and does not constitute a robust recruitment and selection process for the benefit and protection of service users. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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, 39, 42 The quality outcome in this area is poor. This judgement has been made using available evidence including a visit to this service. The home has not been effectively managed for the protection of the people that live there. EVIDENCE: The home has no registered manager. Requirements made at the previous inspection to submit an application for registration of a manager to the CSCI had not been met. It was however, reported that a registered manager from another region had been seconded to cover the post until a permanent appointment could be made. Unfortunately the inspectors were unable to meet this person, but did receive a telephone call from her during the inspection during which assurances were made that immediate requirements would be addressed without delay. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 21 Since the last inspection a representative of the registered provider has begun conducting visits to the home in order to comment on the standard of care provided. There was no indication within the reports sampled of the range of issues identified at this inspection that require action. There is no system of quality assurance in the home. This must be developed to ensure that service users views are sought and acted upon as part of the home’s overall development plan. This report has identified that requirements made at the last inspection remain outstanding, further details of which are provided in the statutory requirements section. Health and safety records were examined. The inspectors were unable to find evidence of service certificates for the passenger lift, fire alarm system, emergency call system, gas safety, portable appliance testing and Legionella control. Immediate requirements were made that copies be sent to the CSCI. Fire safety records were sampled which showed that the fire alarm system and emergency lighting had been tested on a regular basis. Fire safety awareness training remains outstanding for the majority of staff. It was of concern to note that no staff working the night shift have received training in first aid. It was reported that a deaf service user has equipment that flashes lights in his bedroom to indicate that the fire alarm has been activated. It is necessary that the home establish the effectiveness of the system when the person is asleep so that he can be alerted to the need to evacuate the building in the event of an emergency. Some frozen meat and refrigerated food had not been labelled with the date of opening/freezing, which does not comply with safe food storage practice. In the basement food storage area, the refrigerator door was noted to open directly onto a light fixture, which could break the glass and cause injuries. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 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 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 23 CHOICE OF HOME Standard No Score 1 X 2 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 1 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 1 X 2 X 2 X X 1 X Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 24 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 31/07/06 2 YA3 CSA 2000 3 YA6 15(1-2) 4 YA19YA9YA6 15(1-2) 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 variation application 31/07/06 must be submitted to the CSCI for the service users aged over 65 years. Each service user must 31/07/06 have a written plan of care, which states how their needs in respect of health and welfare are to be met. Individual plans must remain subject to regular review. Pressure relief care plans 31/07/06 and risk assessments must be developed and implemented for the service users at risk of pressure sores. The plans DS0000016854.V294131.R02.S.doc Version 5.1 Page 25 Park Avenue, 17 must clearly state how support is provided at night. Unmet from last inspection. 12(1)(a) Care practice must reflect the guidance stated within individual plans of care. 15(1-2)13(4)b,c Care plans and risk 13(6) assessments for service users who demonstrate challenging behaviour must be reviewed to instruct staff how to manage the behaviour. Unmet from last inspection. Moving and handling guidelines must be in place for service users where required. Service users must be offered opportunities to take part in house meetings. There must be a signed record of monies given to service users whilst they are in hospital. Two staff must sign the record in the event that the individual is unable to do so. The home must confirm to the CSCI that there are sufficient staff working in the home who can communicate using British Sign Language. Risk assessments must be dated to evidence that they are relevant to individual’s current needs. 5 YA6 31/07/06 6 YA23YA9YA6 31/07/06 7 YA9YA6 13(5) 31/07/06 8 YA7 12(3) 31/07/06 9 YA7 13(6) 31/07/06 10 YA7 12(4)(b) 18(1)(a) 31/07/06 11 YA9 13(4)(a-c) 31/07/06 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 26 12 13 14 15 16 17 18 19 20 Staff must receive training in care planning and risk assessment. YA17YA13YA12 16(2)(m) Service users social and leisure needs must be assessed and individuals provided with opportunities to take part in activities that meet their preferences. YA16 12(3) Service users must be consulted about the timing of meals and practice must reflect the outcome of such consultation. YA17 16(2)(i) Food must be available for service users in sufficient quantities to meet their needs. YA17 17(2) Sch 4(13) Records of food consumed by service users must be maintained. YA17 13(1)(b) The service user with swallowing difficulties must be referred to Speech and Language Therapy Services and the Dietician for assessment. Care practice must reflect the outcome of such assessment. YA17 16(2)(i) Service users must be consulted about the range of food provided and menus must reflect the outcome of such consultation. YA17 23(2)(f) A review of the dining space must take place, which is reflective of service users individual needs. YA18YA17 12(4)(a) Alternatives to green paper towels must be provided at mealtimes. DS0000016854.V294131.R02.S.doc YA6YA9 18(1)(a) 31/07/06 31/07/06 31/07/06 25/05/06 31/07/06 12/07/06 31/07/06 15/08/06 31/07/06 Park Avenue, 17 Version 5.1 Page 27 21 YA19 17(1)(a) Sch 3 22 23 YA19 YA19 13(1)(b) 13(1)(b) 24 YA20 13(2) 25 YA20 13(2) 26 YA20 13(2) 27 YA20 13(2) 28 YA20 13(2) Health care records must include the reason for each appointment and the outcome. Service users must be offered regular dental appointments. The service user requiring a GP appointment following recommendation by the emergency services must be supported to do so. All medicines must be administered according to times detailed on the prescription label or MAR. Medication must be available for service users as prescribed. The manager must investigate the reasons for Benzhexol not being administered on 24/5/06. Written protocols must be developed and implemented for service users who take PRN medication. Clear, written information must be provided with regard to the (blood sugar reading) range acceptable for each service user with diabetes and must include the action to be taken if readings are outside this range. This must be communicated to staff. A separate fridge for storing medicines must be provided. This must be fitted with a lock and a record of the temperature maintained. 31/07/06 31/07/06 27/05/06 27/05/06 25/05/06 27/05/06 26/05/06 01/06/06 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 28 29 YA20 30 YA20 31 YA20 32 YA20 33 YA23 The manager must investigate the reason for the member of staff employed as a driver taking blood sugar readings and signing the MAR. 13(2) Staff must be provided with accredited training in the safe handling of medicines. 13(2) The manager must ensure that Lactulose and Lithium recorded as out of stock on the MAR are not prescribed and the MAR amended to reflect actual events. 13(2) The medication policy must be reviewed to ensure it is relevant to the services provided at the home. 13(6)18(1)(c)(i) Staff must receive training in adult protection. Unmet from last inspection. The home must take action to address the following matters- repair or replace carpets burned by cigarettes, - make pull cords in bathrooms accessible, - remove handwritten labels on service users furniture, unless they are for their benefit. Unmet from last inspection. A review of lighting must be conducted to ensure that equipment is in working order in service DS0000016854.V294131.R02.S.doc 13(2) 31/07/06 15/08/06 31/07/06 15/08/06 15/08/06 34 YA26YA24 23(2)(c, d) 31/07/06 35 YA24 23(2)(c) 31/07/06 Park Avenue, 17 Version 5.1 Page 29 36 YA26YA24 23(2)(c)(d) 37 38 YA24 YA26 23(2)(b) 23(2)(m) 39 YA26 12(4)(a) 40 41 YA30 YA30 12(4)(a) 13(3) 13(3) 42 43 44 YA30 YA30 YA42YA30 23(2)(d) 13(3) 13(3) 13(4)(c) 45 YA42YA35YA32 18(1)(a) users bedrooms and communal areas. The home must take action to address the following matters – - repair or replace broken handles on bedroom furniture - redecorate ceilings that show patches of damp - replace the carpet in bedroom 10 The ground floor toilet must be repaired. The mobility scooter in bedroom 13 must be removed and stored securely. Service users must be offered a key to their bedroom door based on their individual needs and preferences. The soiled bedding in room 5 must be changed. Bars of soap must be removed from communal bathrooms to reduce the risk of cross infection. Bathrooms and bath seats must be cleaned on a regular basis. Paper towels must be provided in the laundry room. The manager must ensure that staff signed off sick do not work within the home during periods of sickness. A review of staff training must take place and an action plan submitted to the CSCI to confirm the arrangements to provide both mandatory and service user specific training to all staff. 31/07/06 26/05/06 26/05/06 31/07/06 25/05/06 26/05/06 25/05/06 08/07/06 31/07/06 15/08/06 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 30 46 47 YA34 YA34 7, 9, 19 Sch 2 7,9,19 Sch2, 4 The home must evidence that all staff have a satisfactory CRB check. Staff recruitment records must be maintained in accordance with the Care Homes Regulations (2001). Unmet from last inspection. A copy of the staff training matrix must be sent to the CSCI. Unmet from last inspection but received at time of writing report. The responsible individual must advise the CSCI of the arrangements to submit an application for registration of a manager. Unmet from last inspection. The home must develop and implement a system of quality assurance to review and improve the standard of care provided in the home and make provision for consultation with service users within the process. Copies of service certificates for portable appliance testing, the passenger lift, emergency call system, fire alarm system, gas safety and Legionella control must be sent to the CSCI. The home must ensure that equipment provided to alert deaf service 31/07/06 31/07/06 48 YA35 18(1)(a)(c)(ii) 01/06/06 49 YA37 8, 9 31/07/06 50 YA39 24(1-3) 15/08/06 51 YA42 13(4)(a-c) 31/07/06 52 YA42 23(4)(c)(i) 31/07/06 Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 31 53 YA42 13(4)(c) 54 YA42 13(4)(c) users to the fire alarm system being activated at night is effective. Refrigerated food and 25/05/06 frozen meat must be labelled with the date of opening/freezing to comply with safe food storage practice. A risk assessment must 31/07/06 be conducted with regard to the placement of the basement refrigerator near to the light fixture to reduce the risk of accidents. 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 YA7 YA12 Good Practice Recommendations Consideration should be given to the appointment of staff that can communicate using BSL and staff training in this area. Consideration should be given to storing photographs of service users taking part in activities in an area that is accessible to them. Park Avenue, 17 DS0000016854.V294131.R02.S.doc Version 5.1 Page 32 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.V294131.R02.S.doc Version 5.1 Page 33 - 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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