Inspection on 01/08/06 for Raymond Avenue, 24

This inspection was carried out on 1st August 2006.

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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Raymond Avenue, 24 04/04/09

Raymond Avenue, 24 18/03/08

Raymond Avenue, 24 19/01/06

Raymond Avenue, 24 08/08/05

Raymond Avenue, 24 15/02/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Raymond Avenue, 24 Great Barr Birmingham B42 1LX Lead Inspector Donna Ahern Unannounced Inspection 1st August 2006 12:35p Raymond Avenue, 24 DS0000061703.V304705.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 Raymond Avenue, 24 DS0000061703.V304705.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. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Raymond Avenue, 24 Address Great Barr Birmingham B42 1LX 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) 0121 357 0667 0121 357 0668 Platinum Care Services Ms Debbie Collins Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate 5 service users under 65 for reasons of learning disability. 19th January 2006 Date of last inspection Brief Description of the Service: The home is located in a residential area, set back from the main road, up a short drive. It is not distinguishable as a care home, as it is a converted and extended residential property. There are five single bedrooms each with ensuite, a lounge, dining room, relaxation area, large kitchen, laundry, ground floor wc and gardens to both the front and rear. The home is located in North Birmingham, close to the Scott Arms shopping centre. The home is close to local amenities, including the One Stop Shopping centre, parks, canal sidewalks, and leisure facilities. The home has a vehicle and service users are also supported to use public transport. The first floor of the home is only accessible to people with full mobility. A disabled toilet, and two ground floor bedrooms have been provided. The home offers care to five men with a Learning Disability and additional needs including sensory impairment, autism, and behaviours that can challenge. The fee level is £1800. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork visit was unannounced involved one inspector and took place on an afternoon and evening lasting seven and a half hours. This was the homes first key inspection for the inspection year 2006-2007. During the visit the inspector met with all four men who live at Raymond Avenue, to observe the opportunities and support provided to them, to look at the premises, and to read records about care, staffing, and health and safety. One of the men that live at Raymond Avenue spoke openly about their experiences of the home. One resident was recently supported to move on to a new home leaving one vacancy. Time was spent with the registered manager and discussions took place with the two senior staff and two support staff. A pre-inspection questionnaire was completed by the registered manager and returned to CSCI prior to the fieldwork visit. Information from this was used to help compile this report. The home is required to report incidents, accidents and other events that occur in the home to CSCI. These are called regulation 37 notifications. All information reported via a regulation 37 notifications since the last inspection was analysed prior to the fieldwork visit. What the service does well: Raymond Avenue is very homely and domestic environment. There is a friendly and relaxed atmosphere. The men appeared to feel very comfortable in the home, and were able to move around freely, and to access all communal areas of the home. Upon arrival at the home one of the residents showed the inspector around the communal areas of the house. He said, “I really like living here and I don’t want to move again”. The men all have a single bedroom with an ensuite bathroom. The rooms all contained items that were important to the person. Residents were seen freely accessing all areas of the home including spending time in their own room. There is a stable staff team. The home does not use agency staff. This gives the men opportunity to get to know the people who support them, and gives staff chance to become familiar with the men’s needs and routines. One staff member said, “It is a good home to work at I get good support and training to do my job”. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 6 The local authority environmental services undertook an inspection in March 2006 and their findings were entirely positive. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 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 Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 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): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The Statement of Purpose and Service Users Guide give useful information so that prospective residents can make a choice about where to live. Full assessments are undertaken prior to admission. EVIDENCE: Four people live at Raymond Avenue they are all currently men aged between and have a learning disability and additional needs including sensory impairment, autism, and behaviours that can challenge. The service is not however exclusively for males. The Statement of Purpose and Service User Guide contain all the required information and had been produced in an easy read format making it more accessible for some of the people who live at the home. A copy is given to residents and a copy is also placed on resident’s files so they have information about the home. There had been no new admissions since the previous inspection. Sampled case files had copies of the Care Management assessments and assessments undertaken by the home. Individual detailed care plans have been developed for all residents and have been kept under review. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 9 One of the residents said, “I really like living here and I don’t want to move again”. The needs of the current residents are complex and some restrictions based on risk assessments have been implemented such as a coded pad on the front door and locking of the laundry so that the resident’s health and safety is protected. Details of these restrictions were seen on individual case files. The home had one vacancy the manager said that compatibility with the current residents would be paramount when considering referrals. The homes admission criteria had been assessed as meeting the standard at the previous inspection. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 10 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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Comprehensive information is available on each resident. Some development is required so that there is evidence of resident involvement in the care plan process. Risk assessment must be implemented for the support required from night staff so that residents needs are met and their safety and wellbeing protected. EVIDENCE: The previous inspection report required that people’s files were reorganised so that information was easy to find. This had been actioned and information has been organised into different files including a general file, essential information file, everyday file and personal activity file. The people who live at Raymond Avenue have very complex needs and associated disabilities including autism, sensory impairment and behaviour that challenges. Comprehensive information is available on each resident so that staff know how to meet residents very individual needs. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 11 Accessibility and the storage of information had also been improved so that confidentiality is respected and protected. A storage cupboard located in the quiet room enables staff to access the information they require to support residents on a daily basis and the main files are secured in the office. Two peoples files were assessed. Detailed information is available on supporting residents. Reviews had taken place with Social Care and Health and minutes and annual reviews were on case files. There was good information about the persons likes and dislikes, health needs, personal care, culture and preferences. There was detailed information about the person’s communication needs and how staff should promote the person communication. There was evidence that staff had consulted with a range of professionals to promote best practice for the individual. Speech and Language had been involved with the one person to develop their communication skills. A key worked system is established and some minutes of key workers meetings were seen on file. The minutes highlight any “action points” and it was suggested that this specifically states any changes that may be required to the persons support plan. Further development of people’s plans is required so that all residents have the opportunity to partake in Person Centred Plans as identified in the Government White Paper. The previous report required that risk assessments were developed so that they fully address and underpin the risks residents take and are exposed to. Considerable work has been undertaken and a new risk assessment format has been implemented. Risk assessments required implementing for the support residents require during the night from waking night staff. The risk assessments should be used to inform the practice. There should be specific information about how residents are checked on during the night for instances are discreet checks done from outside a person’s room or do night staff specifically check a person, if so why and how should they do this. It was advised that evaluation sheets are placed alongside the risk assessments so that any related incidents are logged and can evidence that the risk assessments are kept under review. It is advised that the support plan part of the case file, which includes peoples routines and how support with personal care should be given, cross references to relevant risk assessments. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 12 Behaviour management strategies were on sampled files had been kept under review and gave information on how best to support residents. The afternoon handover session between staff was observed. Appropriate discussions took place and resident’s needs were discussed in line with their care plans thus ensuring the continuity of care. Observations took place at different times throughout the fieldwork visit residents received good support from staff that spoke calmly and respectfully. Staff were present in the communal areas of the home at all times ensuring residents safety and welfare. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents are supported to undertake activities in the community. Further development is required so that the range and purpose of activities is clear. EVIDENCE: The previous inspection report required that further work was required to ensure that the purpose of activities is clear. Progress had been made. All resident has an activity file, which include a weekly schedule, aims and objectives of the different activities both home based and in the community. It was really positive that a holistic approach to the planning of the activities is considered so that when facilitating activities with residents the person likes, educational, health and social and well-being are all considered. Records of activities indicate that a lot of community activities are “a drive out”. Sometimes the purpose of the activity is not always clear in the recording and further development is required. This was also raised at the previous inspection. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 14 The activity plan for the one resident said that on the day the inspection took place one of the residents should of been supported to go out one to one “to a place of their choice”. What actually took place was that all residents went out for a drive together to get toiletries and have a drink. In the morning all four residents had been out for a drive and to the weight clinic. Observations and discussion with residents and staff indicated that there is evidence of good practice. One resident talked about an Elton John show he had been to and he was looking forward to going to see Chitty Chitty Bang Bang at the theatre next week. He also said that he was going out for a meal with his key worker. A staff member also responded to a spontaneous request from a resident to go out for a walk. Interactions between residents and staff were very positive. Staff were always present supervising residents and engaging in conversations. Two residents were planning a holiday to Butlins and two residents will be supported to go on day trips appropriate to their needs. All four residents have contact with their family. Discussions with staff indicated that they really value resident’s relationship with their family and will facilitate contact. Care plans had details regarding how to support a resident to make telephone calls to their family. In the handover session between staff the senior support worker requested that the afternoon staff supported a resident to make a telephone call to their relative as they had made a request to do so. One of the residents showed the inspector the kitchen he said “I can make a drink when I want to”. Lunch was observed and residents were given appropriate support to eat their meal. Residents different needs at meals times had been considered. One residents will on occasions choose to eat their meal on their own this is respected. Two of the resident’s required close supervision and staff were present through out the meal. One of the residents said he was on a diet and was really pleased about the weight he had lost he said, “I can breathe a lot better now”. Staff spoke to the resident about healthy food and were helpful and encouraging in their tone and manner. A risk assessment and seating plan is in place for the dining room so that the individual requirements of residents are considered and so that resident’s safety is paramount. Food stores and stocks where not examined at this inspection. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. 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 the service. Residents are well supported to undertake a wide range of healthcare monitoring appointments, and the staff had sought advice from a variety of health professionals. EVIDENCE: Care plans had details regarding how residents should be supported with their personal care needs. Residents personal appearance was good and indicated that residents receive good support to attend to their personal care needs. They wore clothing appropriate to their age, culture and time of year. The home has a stable staff team which gives continuity of care. There is a high ratio of male carers, which is positive for the residents who are currently all male so when possible residents can receive intimate care by a person of the same gender. The manager has continued to develop health action plans; a health action plan is a plan of what a person needs to do to stay healthy. Specific health Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 16 needs had been identified and goals set to promote good health such as weight management in line with body mass index. Resident’s files had details of visits to a range of professionals. The care plan of one resident with epilepsy had been developed so that there was information about the person’s epilepsy and the required action from staff to support the resident. The person is not on rescue medication. Clarification is required from a medical practitioner to confirm that the written procedure is appropriate for the individual. Risk assessments and guidelines required implementing for the use of wheelchairs. These must specify the use of lapbelts/posture belts and when they are used and should also specify that wheelchairs be used in accordance with manufactures guidelines to ensure the safety of the person using the chair. Previous reports have commented on improvements around medication management. Medication is stored in a separate locked room. Medication records were sampled. Medication administration records (MAR) had been signed when medication had been administered. The manager stated that medication checks are now completed daily to minimize errors. All senior staff or shift leaders administer medication. Staff undertake training from Boots the Chemist and internal competence assessments on medication management are completed. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. 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 the service. Residents are listened to. Arrangements are in place so that residents are protected from abuse. Information about how to complain must be produced in a format that residents can understand and follow. EVIDENCE: The complaints policy was generally robust, and if followed would ensure that a concern or complaint was thoroughly investigated. The policy had been updated (February 2006) to include the Commission of Social Care Inspection contact details. The policy must be developed in a format that is suitable for the people who live at Raymond Avenue so that it is easier for people to understand and follow. The home had not received any complaints since the previous inspection and CSCI had not received any concerns, complaints or allegations about the home. One of the residents would be able to verbally raise their concerns. The other residents would require considerable support to do so and are therefore dependent on a proactive staff team to protect their wellbeing. Staff are trained in protection matters this was evidenced on the training matrix. Staff spoken to said they felt confident about raising any practice issues or concerns with their manager. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 18 The policy for Adult Protection was underpinned with a copy of the Birmingham Multi Agency Guidelines and had been developed (February 2006) so that it directs staff to contact the placing Social Care and Health office. CSCI have been notified of incidents that have occurred in the home. Regulation 37 reports have been completed logged and forwarded for information. It is advised that the homes logging system for such incidents are developed so that there is a thorough paper trail in place to demonstrate that issues have been dealt with appropriately. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a comfortable home with facilities provided to suit their needs and promote independence. Some of the furnishings and décor required attention to ensure the comfort and safety of residents. EVIDENCE: There is a good range of communal space including a lounge, spacious kitchen, dining room and relaxation area are provided for residents. New leather sofas s and new dining room chairs had been provided since the last inspection. All bedrooms are single and fitted with ensuite facilities. Two rooms were seen and were comfortable and had been personalised. The previous requirement to provide storage for toiletries in resident’s ensuites had been actioned. Some environmental adaptations recommended by the occupational therapist had been provided which included making one of the shower rooms a safer environment for residents. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 20 To meet the very specific needs of residents some environmental adaptations have been obtained which include a specialist chair, eating utensils, and a pressure sensor alarm. There is a garden to the side and rear of the house and there are plans to further develop these areas to provide a more pleasant area for residents use. The manager said that the carpets are regularly cleaned they are light in colour and unfortunately show evidence of a lot of wear and tear and will need replacing. Some areas of the home require repair to plaster work and decoration due to wear and tear. It was agreed that a copy of the planned maintenance and renewal programme would be forwarded to CSCI. The local authority environmental services undertook an inspection in March 2006 and their findings were entirely positive. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Resident’s benefit from a well supported staff team. EVIDENCE: The rota shows a minimum of three staff are provided on duty. The manager’s hours are in addition to this. Staff allocation was adequate for residents to undertake activities of their choice, and to receive the level of support they require. Occupancy levels are down by one person to four the manager confirmed that staffing levels would be reviewed when the vacant bed is filled and staffing appropriate to their needs will be provided. The home has a stable staff team, and some of the staff had worked with the residents since they moved into the home. Staff spoken to presented as enthusiastic and knowledgeable of residents needs. It was evident that some staff and residents had got to know each other very well. Interactions between staff and residents were entirely positive, and the way residents were supported was sensitive and respectful. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 22 Three staff files were assessed. The records of staff recruitment contained all the required documents and ensure that residents benefit from appropriately recruited staff to protect them from harm. Staff have received supervision on a regular basis, and the records of this shows that the sessions are detailed and supportive. It was advised that supervision contracts are implemented to confirm the purpose and frequency of supervision. Staff spoken to during the fieldwork visit said they felt well supported by the manager. Staff files contained details of training courses undertaken. A copy of the training matrix was forwarded to CSCI.It was not evident that all mandatory training had been undertaken to the required level. This must be explored and provided to ensure that staff have the skills and knowledge individually and collectively to meet residents needs. It was positive that staff had undertaken some training in the specific needs of residents such as challenging behaviour and autism these dates must be added to the training matrix. An induction programme is in place however an induction checklist which covers introduction to the home residents needs and care plans, policies and procedures, health and safety and fire procedures, aims and objectives of the home, first aid and emergency procedures and on call arrangements must be implemented so the manager can evidence that these matters have been addressed with all employed and relief staff. It was positive that staff had undertaken some training in the specific needs of residents such as challenging behaviour and autism. Raymond Avenue, 24 DS0000061703.V304705.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Health and safety is generally well managed some minor development matters were identified. Resident’s benefit from a well run home. EVIDENCE: The manager has undertaken training in care and management to the required level. She has significant experience in supporting the needs of this service user group. There is a deputy manager and two senior staff who support the manager. Health and Safety is generally well managed and ensures the safety of residents and staff. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 24 Fire tests and servicing had been undertaken as required. A risk assessment for the safe evacuation of a resident with sensory impairment had been implemented. An independent assessor had undertaken a Work Place Fire Risk Assessment in September 2005 and a full report was available. The fire, electrical and gas supply had been serviced and tested as required. Records showed that staff are undertaking hot water delivery temperatures monthly so that residents are protected from the risk of scalding. A system for the regular cleaning of showerheads must be implemented to comply with health and safety legislation and protect residents from harm. A general risk assessment for the premises was in place and it was advised that this was further developed so that a safe environment is provided for residents and staff. Risk assessments were due to be reviewed. Accident records were appropriately completed and data protection compliant. The manager had implemented a system to ensure that accidents are reviewed and audited to provide an over view of the accidents, and action taken to minimise their re-occurrence. The accident procedure required some minor development so that it is clear that not just accidents requiring hospital treatment are reported to CSCI but other significant accidents such as falls. The log of regulation 37 incidents required some development so that there is brief information about the incident to assist with the tracking of information. Incidents reports required some minor amendments so that they cross reference to documentation that has been completed such as accident book and regulation 37 notifications. Regulation 26 visits are undertaken monthly. These are undertaken to a high standard, and an action plan to address any shortfalls developed. Copies of the reports are forwarded to CSCI. Raymond Avenue, 24 DS0000061703.V304705.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X 2 2 3 Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 Regulation 12(1)(a) 12(3) Requirement Timescale for action 31/10/06 2. YA9 13(4)(a-c) 3. 4 YA14 YA14 16(2)(m-n) 12(3) 16(2,m-n) Some further development of care plans is required so that there is evidence of opportunity for residents to partake in Person Centred Planning as identified in the Government White Paper Valuing People. Risk assessments must be 31/08/06 implemented for the support required from night staff. The purpose of activities 31/08/06 must be made clear. Systems that evidence how 31/08/06 activities are chosen and planned must be developed. Progress made further development required. Risk assessments and guidelines required implementing for the use of wheelchairs. These must specify the use of lapbelts/posture belts and when they are used and should also specify that wheelchairs be used in 5 YA18 13 (4) 12 (1) a,b,c 31/08/06 Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 27 6. YA19 12(1)(a) 7 YA22 22 (2) 8. 9 10 YA24 YA24 YA24 23(2)(d) 23 (2) (d) 23 (2) (d) 11 12. YA35 YA35 18 (1) (c ) 18(1)(c ) 13. YA41 13(4c) accordance with manufactures guidelines. Clarification is required from a medical practitioner to confirm that the written procedure for epilepsy management is appropriate for the individual. The complaints policy must be developed in a format that is suitable for the people who live at Raymond Avenue so that it is easier for people to understand and follow. Damaged plaster, must be repaired or replaced. Carpets required cleaning/replacing. It was agreed that a copy of the planned maintenance and renewal programme would be forwarded to CSCI. The homes induction programme must be formalised. The manager must ensure all mandatory training is provided at the required level to all staff. An accident policy and procedure must be available in the home. Minor addition to the policy required. A system for the regular cleaning of showerheads must be implemented. The log of regulation 37 incidents required some development so that there is brief information about the incident to assist with the tracking and monitoring of information. DS0000061703.V304705.R01.S.doc 31/08/06 30/09/06 31/08/06 30/09/06 31/08/06 30/09/06 30/10/06 31/08/06 14 15 YA42 YA42 16 (2) j 13 (4) 31/08/06 31/08/06 Raymond Avenue, 24 Version 5.2 Page 28 16 YA42 13 (4) 17 YA42 13 (4) Incidents reports required some minor amendments so that they cross reference to documentation that has been completed such as accident book and regulation 37 notifications. The risk assessments for the environment required some further development. 31/08/06 30/09/06 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 YA36 Good Practice Recommendations It was advised that supervision contracts are implemented to confirm the purpose and frequency of supervision. Raymond Avenue, 24 DS0000061703.V304705.R01.S.doc Version 5.2 Page 29 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. 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