Inspection on 26/01/07 for 17 Park Avenue

This inspection was carried out on 26th January 2007.

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

The inspector found 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 9 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 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 Key Unannounced Inspection 26th January 2007 10:00 Park Avenue, 17 DS0000016854.V324838.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.V324838.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.V324838.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) 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.V324838.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. 25th May 2006 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 service users 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 service users at 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 service users in their first languages. The inspectors did not obtain confirmation of the fees charged to service users for living in the home at the time of writing this report as the pre inspection questionnaire (which provides this detail) had not been received. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key fieldwork took place over one day by two inspectors and an interpreter who helped receive comments from service users about the care they get from staff and their experiences of living in the home. The pre inspection questionnaire sent by the CSCI had not been received when the visit took place as the home’s manager had been on holiday and therefore unable to complete it. The questionnaire had not been received at the time of writing this report. Records about service users care and support were looked at as well as staff recruitment and training records and health and safety records. A tour of the premises took place and medicine storage and administration was observed. The inspectors and interpreter had lunch with some of the service users and staff. This was the home’s second key inspection for the year 2006-2007 and there were no immediate requirements made as a result of this visit. The management of 17 Park Avenue has been of concern to the CSCI following the last two inspections. The appointment of a new manager has led to better outcomes for service users and there have been considerable improvements to the appearance of the home, which were observed at this visit. What the service does well: Visitors to the home are made welcome and service users have opportunities to see their friends and relatives in private. Service users cultural and religious needs are well planned for understood and met. Staff have the skills to talk to service users in their first languages. Staff understand service users personal care needs and make lots of effort to help service users manage their care. Service users know how to make complaints about the home and their views are listened to and acted upon. Staff have made good relationships with service users and know them well. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Service users need a contract so they know the terms and conditions of living in the home. The service user guide needs to be looked at to make sure service users can understand the information contained in it. Sometimes medication is not well managed which does not protect service users living in the home. Staff need to have supervision regularly so that they can work more effectively with service users. The home needs to send the details of the staff team’s training to the CSCI so that they can evidence that training has been provided. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 7 Fire alarm safety checks need to be done more often to make sure that the home is safe to live in. 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.V324838.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.V324838.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, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users do not have full access to accurate information to enable them to make an informed choice whether to live in the home. There is an assessment tool, which is used to assess the needs of potential service users so that they can be confident their needs can be met within the home. Service users do not have access to accurate and up to date information about the terms and conditions of living in the home. EVIDENCE: There is a service user guide and statement of purpose, which describe the services and facilities provided in the home. The service user guide is presented in large print and features some pictures in addition to written English. Discussion took place with the home’s manager regarding the accessibility of the information considering that many service users’ first language is not English. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 10 Further work is needed to present the service user guide in a format that is reflective of service users’ communication needs to ensure that individuals receive clear and understandable information about the home, to assist them to make an informed choice about whether to move in. The home has an admission and assessment procedure. This was observed to contain satisfactory detail to enable the home to determine that new service users needs can be met. Upon sampling of service users records it was noted that some files did not contain contracts that explain the terms and conditions of living in the home. In one case, the contract had not been filled in and in another (dated 2004) there was no information about the fees charged for services provided. This must be reviewed to make sure that service users have access to accurate and up to date information about the terms and conditions of living in the home. Park Avenue, 17 DS0000016854.V324838.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. Care planning and risk assessment has improved so that service users needs are more clearly recorded for their protection and well being. Some care plans do not identify the rationale of care practice, which could intrude upon service users privacy. Service users make decisions about their lives and are supported by staff to do so. EVIDENCE: Four care plans were sampled and were noted to have improved since the last inspection. There was information about the person’s daily routines and the help they need with them, how to communicate with the person and their physical and mental health care needs. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 12 There were clearer links to risk assessments and guidelines to manage service users behaviour as part of the care planning process to promote individual’s well being and offer consistency of care. Good detail was recorded to describe service users religious and cultural needs and all staff spoken to at this visit demonstrated a commitment to providing care that was consistent with service users religious and cultural beliefs. Within three of the plans sampled it was recorded that service users needed to be checked every hour at night. There was no rationale for this practice, which could be considered intrusive unless risk assessment identified a need to do so. This must be clarified within each person’s plan of care. One care plan contained conflicting information about the service user’s religion. This was described by staff as being an oversight, however it is necessary that care plans accurately reflect service users needs and preferences to ensure that consistent care is provided. Staff were observed offering service users choices about what to eat and where they wanted to go during the day. Three service users said that house meetings take place and there were records available to further support this. One service user commented, “I can do things my way here, the staff help but they know I want to do things my own way”. Another said, “I chose my new bed covers for my room”. A visitor that spoke to the inspectors said that his relative made lots of choices about his lifestyle and had been supported by staff to access the local Mosque and buy clothing that was reflective of his culture and religion. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in their preferred activities so that they experience a meaningful lifestyle. Service users are supported to keep in touch with their friends and relatives. Individual dietary needs are planned for and food is offered that is reflective of service users religion and culture. EVIDENCE: The care plans sampled showed that service users leisure preferences had been recorded. Daily records and conversation with service users indicated that activities do take place on a regular basis and reflect individual preferences. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 14 Daily records were better organised than at the last inspection so it was possible to judge how service users had spent their time in the home and community. At this visit some service users chose to go to Star City to see a film, others went out to the local Mosque or Gudwara, or stayed at home watching television, receiving visitors and playing board games with staff. One service user said, “It’s really good that we have Sky (television) so I can watch the Indian films”. Three service users told the inspectors that they had opportunities to go out and use local resources such as shops and public transport. One service user spoke about her enjoyment of a college course that she attended. Staff and service users confirmed that visitors were welcomed to the home and offered a meal and drinks during their visit. A visitor commended the home for their care of his relative and said that staff were always friendly and helpful. Another visitor said that he could see his relative in private, which he thought was good. The dining area in the home remains crowded, with the tables and chairs placed within a relatively small space. Some effort had been made to provide additional dining facilities in the lounge, which leads onto the dining room. The registered manager and a representative of the registered provider confirmed that they are aware of the impact of such a small space on the comfort of service users and are researching ways of increasing the space available. Food supplies were observed and found to be sufficient for the number and needs of people living in the home. The inspectors spent some time talking to one of the cooks, who demonstrated considerable knowledge of service users food preferences and in particular the need to provide a culturally sensitive diet and store food appropriately. The cook confirmed that English dishes were offered on a regular basis, which service users said they wished to be provided. The inspectors had lunch with some service users and staff. The meal consisted of dhal, sabjee, rice, salad, pickles, chapatti, fruit and rice pudding. The meal was well presented and service users said they had enjoyed their food. A number of comments were made to the inspectors about the food provided, “We get to try more English food. The cook gave us fish and chips which I like”, “The rice is cooked nicely and the dhal is done well” and “The food is very good, I like that we can try cooking”. It was noted that some service users require specific diets for health care reasons. Records were observed that showed individual’s food and fluid intake had been documented to assist them to maintain good health. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 15 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. There are satisfactory systems in place to ensure that service users personal and health care needs are met. Arrangements are not sufficient to ensure that the management of medication protects service users. EVIDENCE: Service users were well dressed in good quality clean clothes that were reflective of their age, gender and culture. It was evident that attention had been given to supporting service users with their personal care. One member of staff spent a considerable amount of time helping a service user get ready to go out, which the service user said was “very good”. Personal care plans were sampled and found to contain good detail describing individual care needs and preferred routines. The home offers same gender support to service users to manage their personal care, which is culturally appropriate. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 16 Health care records were being well maintained. It was evident that health care professionals had been consulted for guidance in supporting service users to maintain good health, including Continence Advisors and Occupational Therapists. Moving and handling guidelines were in place for service users with mobility difficulties, which clearly described how to assist individuals to move around the home safely. Medication storage and administration systems were examined. All medicines were appropriately stored in a locked cabinet to keep them securely. PRN (as required) protocols had been developed to describe the circumstances under which such medicines should be given to service users to maintain their health. The medication administration records for one service user did not match the Adcal tablets in stock and it appeared that one tablet was missing. Two service users had not received their 4pm medication on 25/1/07. A service user’s Epilim had not been signed as dispensed on his medication record. These matters must be investigated by the home so that service users receive their medication according to the prescribed instructions. It was difficult to read the entry on one medication administration record to establish who had dispensed the medicine. It is strongly recommended that the home develop a sample signature list of staff that administer medication so that potential errors can be tracked to individual staff and addressed for the protection of service users. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 17 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 systems in place for service users to make complaints about the service they receive. Service users are confident that their views are listened to and acted upon. Adult protection systems have improved so that service users are protected from abuse and their welfare promoted. EVIDENCE: The inspectors were advised by staff and service users that the home has a complaints procedure. The procedure is available in the entrance hall. Service users told the inspectors that they knew how to raise concerns about the home and had confidence in the staff and manager to resolve any issues that may arise. There have been no complaints since the last inspection. The home has a copy of the Birmingham Multi Agency Adult Protection Guidelines. Since the last inspection there has been one allegation that was investigated promptly using the home’s adult protection procedures, which resulted in a staff member being subject to disciplinary action. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 18 Staff reported having training in adult protection and were clear about their role in protecting vulnerable adults and reporting incidents of suspected or alleged abuse. There was better detail in the care plans sampled to describe how to support service users who demonstrate challenging behaviour, for their own and others protection. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 19 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, 26, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention to maintenance and cleansing has improved so that service users live in a comfortable and hygienic home. EVIDENCE: One inspector took a tour of the premises and found the home to be clean, warm and free from unpleasant odour throughout. There has been considerable work done to redecorate the communal areas of the premises since the last inspection. Carpets in the hall are due to be replaced once the redecoration has been completed. New carpet had been fitted in some bedrooms and a number of service users were pleased that they had had new bedroom furniture. Bedding was clean and some mattresses and beds had been replaced for the comfort of service users. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 20 New extractor fans had been fitted in the kitchen to provide better ventilation. The kitchen was noted to be clean and hygienic. At the last inspection it was noted that pull cords in bathrooms had been secured out of service users reach. This was not the case at this visit. The laundry room was clean and appropriate facilities were available to staff so that they could wash their hands after handling soiled linen and therefore reduce the risk of spreading infection within the home. It was evident that the home was being effectively maintained for the comfort and safety of service users. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by a team of staff that understand their needs. The arrangements for staff training and supervision are variable and could impact on service users well being. Recruitment and selection procedures are robust and protect service users living in the home. EVIDENCE: The inspectors received positive comments from service users about the staff team – “The staff are good, kind and nice”, “Anwar (the manager) is very good” and “I’m happy here thanks to the staff”. From discussion with staff and observation of their interaction with service users it was evident that respectful and friendly relationships had been formed. It was pleasing to note that staff are receiving training in BSL (British Sign Language) to enable them to communicate more effectively with a deaf service user. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 22 Observation of staff training records showed that the provision of mandatory training has improved. However the matrix that confirms the training received by the staff group as a whole was not received at the time of writing this report so it was not possible to evidence that requirements made at the last inspection to provide training to all staff in specific areas such as medicines management had been met. The requirements made are therefore repeated. Examination of recruitment and selection records showed that appropriate checks had been made of individual’s suitability to work in the home prior to employment commencing for the protection of service users. From the five files sampled, four staff members had received regular supervision from September 2006. Prior to this date there were some gaps. One staff file contained no records of supervision. This must be addressed to make sure that staff receive adequate supervision to ensure they are able to work effectively in the home. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. Management of the home has considerably improved and service users benefit from a more well run home. Service users views are encouraged a part of the home’s quality assurance plan. Some areas of health and safety practice and recording need to improve for the ongoing protection of service users. EVIDENCE: The home does not have a registered manager. However the new manager confirmed that he would be submitting an application for registration to the Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 24 CSCI following this visit. This had been received at the time of writing this report. The new manager has been a registered manager at the home in the past and demonstrated commitment to improving the care provided. The appointment of the new manager has led to better outcomes for service users living in the home. Care planning and risk assessment has improved, activities are more organised and reflective of service users preferences, staff recruitment procedures are more robust and the presentation of the premises provides a more comfortable environment for service users. Quality assurance systems have been developed to seek service users views on the running of the home and the standard of care provided. Questionnaires were observed which had been completed by service users and visitors. A representative of the registered provider visits the home each month and writes a report about the quality of care provided. The reports have been made available to the CSCI. Fire safety records were examined which showed that emergency lighting had been tested to make sure it was in working order. The records identified that the fire alarm system had not been tested since 12/1/07. Regular testing must take place to protect service users living in the home. Certificates of maintenance were seen which showed that gas and electrical equipment had been serviced on a regular basis for the protection of service users. A new system of quarterly checks has been introduced as a safety audit of the premises and equipment as a further safeguard for service users. The home records accidents and informs the CSCI of the action taken in response to injuries to service users. It was noted that the storage of accident records was not compliant with Data Protection legislation, which must be addressed to ensure that confidential information about service users is stored within their personal files. It was pleasing to note that all recommendations from the independent fire safety assessment conducted in October 2006 had been met for the ongoing protection of service users. Suitable fire safety equipment had been provided to a service user unable to hear the fire alarm, which was a requirement of the last inspection. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 X 5 2 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 2 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 5(1) Requirement The service user guide must be reviewed to ensure that information is presented in a format that meets service users communication needs. Service users must be provided with an up to date contract that explains the terms and conditions of living in the home. Individual care plans must accurately reflect service users needs. Service users needs at night must be clearly explained within plans of care and checks made as a result of risk assessment to ensure their privacy is respected. Service users must receive their medication according to the instructions of the prescription and records signed to show that this has taken place. Timescale for action 25/03/07 2 YA5 5(1)(c) 25/03/07 3 4 YA6 YA9 15(1-2) 12(4)(a) 25/03/07 25/03/07 5 YA20 13(2) 26/02/07 Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 27 6 YA35 18(1)(a)(c)(ii) A copy of the staff training matrix must be sent to the CSCI. This was identified at the last inspection of 25/5/06. The current matrix has not been received by the CSCI. Staff must receive regular supervision at least six times a year. The fire alarm system must be tested each week to make sure it is working effectively and records maintained of each test. Accident records must be securely stored within individual’s files. 25/03/07 7 8 YA36 YA42 18(2) 23(4) 25/03/07 26/02/07 9 YA42 17(1)(a) Sch 3 25/03/07 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 YA20 Good Practice Recommendations The home should consider the development of a staff signature list as part of the medication procedure. Park Avenue, 17 DS0000016854.V324838.R01.S.doc Version 5.2 Page 28 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.V324838.R01.S.doc Version 5.2 Page 29 - 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. 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