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Inspection on 18/03/08 for Raymond Avenue, 24

Also see our care home review for Raymond Avenue, 24 for more information

This inspection was carried out on 18th March 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Raymond Avenue is very homely and domestic environment. There is a friendly and relaxed atmosphere. People living at the home were very comfortable and were able to move around freely, and to access all communal areas of the home. Upon arrival at the home one person was in the garden and said he liked to go out and smoke his pipe and was able to come and into the garden as he wished. All the bedrooms single with an en suite bathroom. The rooms all contained items that were important to the person giving the rooms a feel of individuality and ownership. People were seen freely accessing all areas of the home including spending time in their own room.There was evidence that the staff and people living in the home had built up good relationships. Staff were able to respond positively to the needs and wishes of people. Staff also were able to respond when people showed signs of distress and were able to deal with situations well and prevent them from escalating. There is a stable staff team. The home does not use agency staff. This gives the people living in the home and staff opportunity to get to know each other and gives staff chance to become familiar with people`s needs and routines. The staff receive the training that gives them the skills provide good care.

What has improved since the last inspection?

There is information about how people are checked on during the night for instances discreet checks from outside a person`s room to night staff specifically checking a person. There are activity records that show what activities people have done and how people have reacted to them. This helps to assess as to whether the activity was meaningful to the person if not then another approach is tried. Guidelines for the management of Epilepsy has been put in place there is evidence that he persons doctor has been involved. Risk assessments and guidelines are in place for the use of wheelchairs. These and specify the use of lapbelts/posture belts and when they are used and specify that wheelchairs be used in accordance with manufactures guidelines. There is an on going programme of repairs and replacement of furniture and carpets. The induction has been updated and is in line with "Skills for Care" guidelines and the training matrix has improved and records both mandatory and specialist training. The health and safety procedures have improved, accidents and incident recording has been improved so that people know what action people have taken when dealing with these. There is also a filing index so that staff can retrieve the information should it be needed in the future. An environmental risk assessment has been developed that includes the checking of the fire system and the cleaning of shower heads in line with the infection control policy.

What the care home could do better:

The action staff need to take in relation to reducing individual risk for people should be readily available to staff. At the time of the visit staff were referred to specific policies. The information should be readily available to staff and kept with the risk assessment.

CARE HOME ADULTS 18-65 Raymond Avenue, 24 Great Barr Birmingham B42 1LX Lead Inspector Donna Ahern Key Unannounced Inspection 18th March 2008 10:00 Raymond Avenue, 24 DS0000061703.V344809.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.V344809.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.V344809.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 Christine Till Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) the service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning Disabilities (LD) 6 The maximum number of service users to be accommodated is 6 Date of last inspection 1st August 2006 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 six 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 £1900 to £2210 per week. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that people using this service experience good quality outcomes. The inspection was carried out was unannounced and was done by one inspector over the course of one day. The inspector would like to thank everyone who took the time to talk to them and express their views. Before the visit, accumulated information about the home was reviewed. This included looking at the number of reported accidents and incidents and reports from other agencies, i.e., the Environmental Health Officer, and correspondence following the last inspection. This information was used to plan this site visit. The inspector case tracked three people’s care plans. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. The inspectors spoke with identified people who live at the home and relevant members of the staff team who provide support to them. Documentation relating to these people was looked at. What the service does well: Raymond Avenue is very homely and domestic environment. There is a friendly and relaxed atmosphere. People living at the home were very comfortable and were able to move around freely, and to access all communal areas of the home. Upon arrival at the home one person was in the garden and said he liked to go out and smoke his pipe and was able to come and into the garden as he wished. All the bedrooms single with an en suite bathroom. The rooms all contained items that were important to the person giving the rooms a feel of individuality and ownership. People were seen freely accessing all areas of the home including spending time in their own room. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 6 There was evidence that the staff and people living in the home had built up good relationships. Staff were able to respond positively to the needs and wishes of people. Staff also were able to respond when people showed signs of distress and were able to deal with situations well and prevent them from escalating. There is a stable staff team. The home does not use agency staff. This gives the people living in the home and staff opportunity to get to know each other and gives staff chance to become familiar with people’s needs and routines. The staff receive the training that gives them the skills provide good care. What has improved since the last inspection? What they could do better: Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 7 The action staff need to take in relation to reducing individual risk for people should be readily available to staff. At the time of the visit staff were referred to specific policies. The information should be readily available to staff and kept with the risk assessment. 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. Raymond Avenue, 24 DS0000061703.V344809.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 Raymond Avenue, 24 DS0000061703.V344809.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 and 5 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide give useful information so that people know the home can meet their needs before they move in. Full assessments are done before people move into the home, staff know the needs of the people and can give the most appropriate care. EVIDENCE: People living at the home are all have a learning disability and additional needs including sensory impairment, autism, and behaviours that can challenge. The Statement of Purpose and Service User Guide contain all the information about the home and the services they provide 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 people and a copy is also placed on their files so they have information about the home. There has been one new admissions since the previous inspection. There was a copy of the Care Management assessments and assessments undertaken by the home. Information was detailed and made available to staff. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 10 This allowed staff to plan the care for this individual taking into account the most recent needs. People said they liked living at the home and there was continuous interaction between the staff and people living at the home. Where restrictions had been made to people’s movements because of their complex needs risk assessments were in place and there safety was secured by restricting access to certain areas such as the laundry. Each person has a written contact on their file that explains what services people can expect and what may be classed as additional services that would not be covered by the fee. Raymond Avenue, 24 DS0000061703.V344809.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 and 9 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is good information on people’ care plans. These have been developed there is evidence of persons involvement in the care plan process. Where possible people do make decisions about their lives and there is evidence that they are supported to do this. Risk assessments are in place so that people’s needs are met and their safety and wellbeing protected. EVIDENCE: Peoples files including a general file, essential information file, everyday file and personal activity file. This information is written in the first person by the key worker and there is evidence that the information is individual to the person it is written for and includes comments from the person themselves or their close family. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 12 The people who live at Raymond Avenue have very complex needs and associated disabilities including autism, sensory impairment and behaviour that challenges. There is good information about each person so that staff know how to meet their very individual needs. Throughout the day people were involved in individual activities, those that were able were making decisions about what they wanted to do and being assisted by staff. Accessibility and the storage of information is good 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 people on a daily basis and the main files are secured in the office. Three people’s files were case tracked. There was detailed information available on supporting each person. Reviews had taken place with Social Care and Health and minutes and annual reviews were on case files. There was good information about the people’s likes and dislikes, health needs, personal care, culture and preferences. This also included any possible triggers that might lead to inappropriate behaviour if the plan was not followed. This information is good as it reduces the risk of unnecessary conflict and tension in the home. There was detailed information about the person’s communication needs and how staff should promote the person communication such as pictures or signing.. Where needed 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 and the dietician with another others. There is a key worker system in place and there is evidence that key workers meet with people on a monthly basis and highlight any area of change that have occurred. Since the last inspection risk assessments have been started for the support people during the night from waking night staff. The risk assessments is used to assess the risk to each person at night. This means that where it is known that people sleep throughout and do not put themselves at risk then they are checked less frequently than others who have more disturbed sleep. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 13 This shows that people are given the right amount of support at night without them being disturbed unnecessarily. There were appropriate risk assessments available for all the people who were case tracked. These were individual to the person and no blanket policies were in place that would restrict all the people because one person was at risk. We recommended that the action staff should take to reduce the risk to people be kept with the assessed risk as at the time of the visit staff were being referred to specific policies that were not readily available. Behaviour management strategies were on sampled files had been kept under review and gave information on how best to support people 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 people received good support from staff that spoke calmly and respectfully. Staff were present in the communal areas of the home at all times ensuring people’s safety and welfare. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported to undertake activities in the community they are given the opportunity to be involved in meaningful activities. Their rights and are respected and there are offered a healthy varied diet. EVIDENCE: Planning activities is done as an holistic part to people’s care. The manager and staff recognise that social activity is as important as the physical care of people. There is an activity file that records people’s individual activity on a weekly basis. Where this is a group activity this would be reflected on each persons record sheet. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 15 The policy on activities says that they should reflect the wishes, preferences and needs of people and make sure they develop with each persons changing needs. There is evidence that the staff have developed meaningful activities with people. People undertake various activities in the community including going to day centres and colleges. The staff have found that one person having the home to themselves is an activity in it’s self for one person because when he has the home to himself he is more relaxed. The staff said that some activities were trial and error to see if people liked specific activities such as swimming, past interest are taken into account and families are asked about these. Staff also record how people react to a tried activity so that a decision can be made as to whether it meets the need of the person. On the day of the visit people were out undertaking various activities on person remained at the home and enjoyed the chance to have the home to him self. Observations and discussion with people and staff indicated that there is evidence of good practice. One resident talked about how he likes to go for a walk or go outside and smoke his pipe. People also enjoy spontaneous activities like going for a pub meal or trip out. Interactions between people and the staff were very positive. Staff were always present supervising people and engaging in conversations. All the people living at the home have contact with their family. Discussions with staff indicated that they really value people’s relationship with their family and will facilitate contact. Care plans had details regarding how to support a person 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. Some people were seen to be assisting making drinks an sandwiches for themselves. One person had his meal on his own as he prefers this. The inspector had lunch with two people and the manager, one of which needed assistance which was given as he needed it. The other was on a diet and though there was Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 16 some leeway in how much he ate staff did remind him appropriately that he was on a diet and he responded positively and with good humour. The dining room has been re arranged as it is only a small room and did have individual tables making it cramped and difficult for staff to assist people. There is now one larger table where people sit together as a family unit. Staff spoke to the people 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 people’s safety is paramount. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 17 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 and20 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are well supported to undertake a wide range of healthcare monitoring appointments, and the staff had sought advice from a variety of health professionals. Medications are administered and recorded appropriately. EVIDENCE: Care plans had details regarding how people should be supported with their personal care needs. People’s personal appearance was good and indicated that people receive good support to attend to their personal care needs. They wore clothing appropriate to their age, culture and time of year. There has been a new manager appointed since the last inspection the home continues to have a stable staff team which gives continuity of care. There Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 18 continues to be a high ratio of male carers, which is positive as people who live in the home are male who are currently all male so when possible people can receive intimate care by a person of the same gender. Care plans contain information on health action plans; a health action plan is a plan of what a person needs to do to stay healthy. Specific health needs had been identified and goals set to promote good health such as weight management in line with body mass index. People’s files had details of visits to a range of professionals. The care plan had been developed so that there was information about each person’s needs and the required action from staff to support the individual. Risk assessments and guidelines are in place for all people in the home these relate to individual risk themselves or to others for instance smoking. We observed the procedure for administrating medications, two members of staff are involved one who administers and signs to say that the medication has been administrated and the seconds signs to say that the medication has 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. The medications are stored in locked cabinets that are designed for there use. Where medications are given with food this has been agreed with the individuals doctor and there is a risk assessment available. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are listened to and arrangements are in place so that people are protected from abuse. Information about how to complain is on display in the home and is in picture format so people find it easy to understand. EVIDENCE: The complaints policy continues to be robust, and makes sure that a concern or complaint was thoroughly investigated. The policy has been developed in a format that is suitable for the people who live at the home to understand and is in a picture format. 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 people living at the home would be able to verbally raise their concerns. The other people would require considerable support to do so and are therefore dependent on a proactive staff team to protect their wellbeing. Staff continue to be 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.V344809.R01.S.doc Version 5.2 Page 20 We have been notified of incidents that have occurred in the home. Regulation 37 reports have been completed logged and forwarded for information. The homes has commenced a logging system for such incidents are so that there is a thorough a paper trail can demonstrate that issues have been dealt with appropriately. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 and 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People 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 people. People’s rooms were comfortable and had been personalised. People had the opportunity to furnish their own bedrooms and have personal items, this gives the rooms of individuality and ownership. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 22 Some environmental adaptations recommended by the occupational therapist had been provided which included making one of the shower rooms a safer environment for residents. The home ha had some environmental adaptations have been made and include a specialist chair, eating utensils, and a pressure sensor alarm. There is a garden to the side and rear of the house and was seen to be used by people on the day of the visit. There is a grassed area and an area for people to it out. The garden has easy access for people who have limited mobility.. 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. As recorded I the last inspection report some areas of the home require repair to plaster work and decoration due to wear and tear. The manager said that this is an on going problem as some people in the home pick the plaster off the wall. There was evidence that repairs are ongoing. The home has an infection control policy and there was evidence of equipment being available to reduce the risk of cross infection including anti bacterial hand wash, disposable gloves and aprons. The home was clean and free from unpleasant odours. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well supported staff team. Staff have specific roles and are aware of their responsibilities. The recruitment procedures are robust and protect people from potential abusers. Staff are trained to meet the needs of the individual people in the home. EVIDENCE: There are three members of care staff, plus an activity coordinator on duty each day. The managers hours are in addition to this. Staff allocation was has improved since the last inspection for people to undertake activities of their choice, and to receive the level of support they require. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 24 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. Observations on the day of the visit showed that people living at the home had built up good relationships. People were seen to confide I staff and staff responded positively to peoples concerns. Interactions between staff and people were entirely positive, and the way people were supported was sensitive and respectful. Staff were able to recognise triggers were people were distressed and were able to act quickly and positively to reduce the stress of the individual and prevent situations out of control. 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 files contained details of training courses undertaken. Mandatory training and specialist training was recorded. Training undertaken by staff includes National Vocational Qualifications at level 3. Prevention form Abuse, Safe Handling of Medications and Health and Safety. The Fire Prevention Officer does fire training. Training relating to Autism and the Management of Epilepsy was done by outside trainers. The home has a number of videos used to refresh staff periodically. Since the last inspection the induction programme has been updated this now reaches “Skills for Care Standards. 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.V344809.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from a home that is well run, views of the people who have an interest in the home are listened too and acted upon. People are protected by the Health and safety procedures in the home. EVIDENCE: There has been a new manager in post since the last inspection and has been registered as a fit person to run a care home by us. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 26 The manager has undertaken training in care and management to the required level. She has significant experience in supporting the needs of people within the home. There are three senior staff, care staff and an activity coordinator who support the manager. Health and Safety is well managed and ensures the safety of residents and staff. Since the last inspection the 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. Since the last inspection a system for the regular cleaning of showerheads has been stared to comply with health and safety legislation and protect people from harm. Since the last inspection an environmental risk assessment has been started and covers twenty two areas in the home. This makes sure that a safe environment is provided for people and staff. Risk assessments reviewed as required.. 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. Since the last inspection incidents and accidents that require to be notified to us under regulation 37 are now filed with an identifying index number. This makes sure that the person dealing with the incident notifies us if required and logs that action on the file. It also allows quick access to information should it be needed on a later date. 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. The home has its own quality audit information relating to medications, food hygiene, health and safety and infection control. These areas are regularly Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 27 monitored and discussed with staff at meetings. This makes sure that people are kept safe and the reduction of risk in these areas are minimised. Quality audits for people living in the home and people who have a significant interest in the home such as relatives has been commenced but the questionnaires had not been sent out at the time of the visit. We recommended that this be commenced as soon as possible and that any action taken in the home as a result of the questionnaires be fed back to people so that there is evidence that the home has is open to suggestion and values the ideas of others. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 28 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 3 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 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 2 Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 29 No 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. Standard Regulation Requirement Timescale for action 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 YA19 Good Practice Recommendations Action staff need to take to reduce risks on individual risk assessments should be readily available on the care plan. Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Raymond Avenue, 24 DS0000061703.V344809.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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