Inspection on 19/01/06 for Raymond Avenue, 24

This inspection was carried out on 19th January 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 36 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 01/08/06

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 Alison Ridge Unannounced Inspection 19th January 2006 11:00 Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 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.V279344.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate 5 service users under 65 for reasons of learning disability. 8th August 2005 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 distingushable 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 ammenities, including the One Stop Shopping centre, parks, canalside walks, 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 accessable 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. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced visit over the late morning and afternoon of one day. During the visit inspectors were pleased to meet with all five of the 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. Two of the men that live at Raymond Avenue spoke openly about their experiences of the home. The inspectors suggest this report be read alongside the report of the previous inspection undertaken in August 2005. This can be requested from the home, the CSCI, or found on the CSCI website. (csci.org.uk) The inspectors extend their thanks to everyone who helped with this visit. What the service does well: Raymond Avenue is very homely and domestic. 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. The men all have a single bedroom with an ensuite bathroom. The rooms all contained items that were important to the person. The five men have lived at Raymond Avenue for over a year, and it was apparent they had been supported to access healthcare. For some of the men the progress made in their wellbeing was very notable. This included successful weight loss, and medication reviews. One of the men inspectors spoke with had been supported to work towards living with greater independence. The work undertaken to get ready for this was very positive, and obviously to the pleasure of the gentleman about to move. 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. The staff buy good quality foods, and a large stock of different foods were available in the home. The men have opportunity to go out of the home on a daily basis. It was positive that significant activities such as pop concerts had been planned, as well as regular opportunities to access the local community each day. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 6 The men are supported to stay in touch with their family and friends. This has included going to stay with them on holiday, and staying in touch by phone. The men, staff and visitors are protected as regular health and safety checks are undertaken in the home, and all equipment is serviced and repaired as required. 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.V279344.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home has a Statement of Purpose and Service Users Guide that give useful information when making a decision about where to live. EVIDENCE: The manager had developed the Statement of Purpose and Service Users guide as had been previously required. These documents now contain all the required information. The manager still needs to make sure the service users guide is provided in a format that service users could understand and access. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9, 10 Some service users needs are underpinned with detailed plans that promote good working practices and consistency. Other parts of the service users care documents require development to ensure all needs are planned for and met. The storage of care records must improve to ensure confidentiality is maintained. EVIDENCE: Parts of the plan of three people accommodated were assessed. The staff had undertaken Essential Life Planning (ELP) with two of the men. This work appeared to be very positive, and one service user reported with pleasure the opportunities made available to him, since he had undertaken the planning. The plans contained a lot of information, and both inspectors found that it was difficult to find current active information, as it was stored alongside historical, and draft documents. The inspectors spoke with the manager about ways of improving the accessibility of information, and ways of avoiding duplication of records. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 10 It was not apparent that staff who had completed service users risk assessments had a clear idea of the purpose of these documents, or how to use the information gathered. The files sampled contained some guidance on risk assessment, but this had not been followed in the plans sampled. All the risk management documents sampled require further development to clearly identify what the perceived risk is and the control measures to be implemented. The interactions between staff, and towards service users were all respectful, and mindful of confidential information. The inspectors were concerned that the storage of care records was not secured, and that visitors, or other service users could access personal or confidential material. It is required this arrangement be changed. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 17 The number of opportunities available to service users to undertake activities in the community was high, however the range and purpose of activities was not clear, and it was not evident that service users are always able to choose activities of interest to them. EVIDENCE: Discussion with two service users, observation during the visit, and the daily records showed that the opportunities for service users to access the community are plentiful. It was pleasing to see staff arrange ad-hoc activities in response to service users requests, and that planned activities went ahead. The service users have been supported to undertake some significant events such as going to a pop concert, running a car boot sale stall and visiting places of interest. The purpose and value of day-to-day activities still needs to be explored and developed. Many of the records showed the activity undertaken was a “drive out” without clear reference being made to the location or purpose of the activity. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 12 The opportunities offered to one service user were tracked against the weeks planned activities. It was not evident why all of the planned activities had not gone ahead. The inspectors spoke with two of the service users about the opportunities to stay in touch with their family and friends. Both the service users were pleased with the opportunities to visit their family, even when this wasn’t in the local area. One service user had a collection of family photos on display in his room. The inspectors considered this was an area of good practice. The food available in the home was plentiful, and of good quality. It included some fresh and frozen fruit, vegetables and salads. The planned menu was very varied and nutritious. The record of food eaten did not tally with the menu, and did not show that such a varied or nutritious diet had been offered. The records did not show that adequate portions of fruit and vegetables were being offered or served. The inspectors were pleased to hear from a service user and staff of the work undertaken to support one service user loose weight. The service user was pleased with the revised menu he had planned, and that he was still able to eat dishes he liked. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Opportunities to undertake personal care to a high standard had been provided, and service users all had ensuite bathrooms to ensure this could be undertaken in private. Service users had been well supported to undertake a wide range of healthcare monitoring appointments, and the staff had sought advice from a variety of health professionals. Specific health needs were not well planned. Medication management has continued to improve, and service users have mainly received the right medication at the right time. EVIDENCE: The service users inspectors met with all appeared well presented, and to have been supported with personal care. In each of the ensuite bathrooms there was an individual supply of toiletries. The morning and evening routines available were very detailed, and showed the service users individual preference regarding their personal care. Healthcare appointments had been undertaken. Records of care showed that service users had been supported to access a wide range of appointments relevant to the needs they have. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 14 The dentist made a domiciliary visit to the home during the inspection and complimented the service users and staff on work undertaken to improve oral hygiene. Some specific health needs including epilepsy were tracked. The plan of care did not provide staff with clear guidance on the usual presentation of a seizure, or how to support the service user with this. The plans for a service user with autism were assessed. The plan made no mention of how this condition affects the individual, and the type of support he requires regarding it. It has been required that all specific healthcare needs be underpinned with a plan that gives staff detailed information on how to support the person. Medication management has significantly improved since the home opened. The system in place does ensure service users get the prescribed medication, when it is required. The manager has reported two medication errors in December 2005. It was evident that lessons had been learnt and the systems amended to reduce the likelihood of such incidents being repeated. The need to formalise the arrangements for service users taking medication out of the home was identified. It was positive staff had undertaken action to improve on the situation. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 There are policies for dealing with allegations of abuse, and complaints. Some minor amendments need to be made to these documents to ensure they are robust. The home has a very open culture in which staff and service users feel able to raise concerns. EVIDENCE: The policy and procedure dealing with Complaints and Adult Protection matters were assessed. The complaints policy was generally robust, and if followed would ensure that a concern or complaint was thoroughly investigated. The following minor shortfalls were noted. The policy needs to be updated to include the Commission of Social Care Inspection, the policy needs to make clear that any person making a complaint will not be victimised for doing so, and that all concerns raised will be taken seriously. It was pleasing when talking with two of the service users to hear that they felt able to raise concerns with any of the staff, or the home manager. It was positive to see that this had also been explored by the Responsible Individual in a recent regulation 26 visit. The policy for Adult Protection was underpinned with a copy of the Birmingham Multi Agency Guidelines. The policy should be developed to contain a list of relevant support organisations. At section 4 the policy must direct staff to contact the placing Social Care and Health office. Both policies were dated April 2004, and must be kept under review. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 7, 28, 29, 30 Service users have been provided with 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 service users. EVIDENCE: It was pleasing to see that the home had been personalised by the service users accommodated. The home has a “lived in” feel, and some damage to plaster work, paintwork/décor and furnishings was apparent. The manager reported that repair and redecoration is ongoing, and further work is scheduled in the near future. The service users all have a single bedroom, fitted with ensuite facilities. Two of the service users reported they were very happy with their room. All the rooms were clean, and very personalised. It was positive that the manager had arranged development of rooms in response to service users needs. The ensuite bathrooms were all clean. It has been recommended that storage for toiletries be provided, and in one ensuite that the bath panel be repaired. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 17 A communal lounge, kitchen and relaxation area are provided for service users. Some environmental adaptations have been obtained which include a specialist chair, eating utensils, and a pressure sensor alarm. It was identified that staff had tried to obtain items as identified by the Occupational Therapist, but that these remain outstanding. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36 Service users benefit from a stable staff team, whom they know, and who have experience in meeting their needs. Staff display a positive regard for service users, and support them sensitively. Recruitment practice needs to improve to evidence that the information collected has been thoroughly checked to ascertain the person’s suitability for the job. Staff receive training and supervision. Some requirements to ensure this is to the required levels have been made. EVIDENCE: The home has a stable staff team, and some of the staff had worked with the service user since they moved into the home. It was evident that some staff and service users had got to know each other very well. The interactions between staff and service users were entirely positive, and the way service users were supported was sensitive and respectful. The rota shows a minimum of three staff are provided on duty. The manager’s hours and on some shifts another 9-5 shift are in addition to this. At the time of inspection the staff allocation was adequate for service users to undertake activities of their choice, and to receive the level of support they require. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 19 The records of staff recruitment contained all the required documents, but did not evidence that they had been robustly reviewed. Examples such as staff not providing references from their most recent employer, or not stating the relationship between themselves and the referee were noted. The need to review and evidence that one person is able to stay and work in the UK was required. Staff have received supervision on a regular basis, and the records of this shows that the sessions are detailed and supportive. The frequency of supervisions needs to increase to meet the bi-monthly target. Staff files contained details of training courses undertaken. It was not evident that all mandatory training had been undertaken to the required level. This must be explored and provided. It was positive that staff had undertaken some training in the specific needs of the service users such as challenging behaviour and autism. Further training in the communication needs of the service users accommodated is required. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,41, 42 The management and operation of the home has improved. Further work to ensure the outcomes for service users are safe, well planned, and consistently met must be undertaken. 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. The senior posts within the home have been reviewed, and new posts recruited to. It is anticipated this will result in better outcomes for service users, and the further development of record keeping systems. There was a current certificate of registration, and employer’s liability available in the home. Regulation 26 visits are undertaken monthly. These are undertaken to a high standard, and an action plan to address any shortfalls developed. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 21 The missing person policy was assessed. This was generally detailed. It is recommended this be developed to include notifying social care and health of the incident, and to refer the reader within the policy to service users individual risk assessments regarding community access and safety. The fire policy was assessed. This was a generic document, and had not been developed to reflect the specific issues regarding evacuation of service users with sensory impairment. The accident policy was not available in the home and must be replaced. The regular servicing and testing of appliances has ensured the health and safety of service users, staff and visitors. The fire, electrical and gas supply had been serviced and tested as is required. Records showed that staff are recording fridge and freezer temperatures and hot water delivery temperatures daily. The manager must ensure the risk of water-borne disease is screened for and effectively managed. Risk assessments for food had been developed. These must be dated, signed and kept under review at least six monthly. A general risk assessment for the premises remains outstanding. The current review interval for all risk assessments is twelve months. The inspectors strongly recommend this be reduced to six monthly, or sooner in the event of a critical incident. The staff had completed accident records. The manager must ensure that these are reviewed and audited to provide an over view of the accidents, and action taken to minimise their re-occurrence. The CSCI must be informed of accidents under regulation 37. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 1 33 3 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 1 1 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 2 X X X 2 1 X Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 23 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 15(1)(2) Requirement Timescale for action 01/03/06 2. YA6 3. YA6 4. YA6 5. YA9 Information that informs and directs care practice must be easily available to staff in the home. 15(1)(2) Not fully met from the previous inspection. 17 Service users plans that meet the requirements of Regulation 15, 17 and schedule 2 of the Care Homes regulations must be developed for all service users. 12(1)(a) Not fully met from the previous inspection. 12(3) Opportunity for service users to partake in Person Centred Planning as identified in the Government White Paper Valuing People must be provided. 12(1)(a) Not fully met from the previous 12(1)(3) inspection. Plans must evidence consultation with the service user or their representative.(If this is not possible evidence as to how conclusions have been reached must be provided.) 13(4)(a-c) Risk assessments must clearly state the risk being assessed and control measures in place to DS0000061703.V279344.R01.S.doc 01/04/06 01/04/06 01/04/06 01/03/06 Raymond Avenue, 24 Version 5.1 Page 24 address it. 6. YA9 13(4)(a-c) Risk assessments must be developed that fully address and underpin the risks service users take and are exposed to. 12(4)(a) Personal records about service users must be stored securely within the home. 12(1a) Communication systems as 12(4b) assessed as being required by service users must be provided, and in operation in the home. 16(2)(mService users must be offered n) opportunity to undertake personal development. 16(2)(mThe purpose of activities must be n) made clear. 12(3) Not met from the last inspection. 16(2,m-n) Systems that evidence how activities are chosen and planned must be developed. 12(1)(a) Not fully met from the last 15 inspection Opportunity for weight monitoring must be offered to service users. 12(1)(a) Not met from the last inspection Care plans that underpin how additional healthcare needs including epilepsy and behaviour must be developed. 12(1)(a) Not met from the last inspection 12(3) Service users must be supported in the development of Health Action plans. 12(1)a Not assessed at this inspection. 13(4)c Behaviour management plans 13(6) that contain proactive and reactive measures must be developed. 13(2) Not fully met from the last inspection Medication management must be developed to ensure that, protocols for all as required medicines are provided. 13(2) The home must risk assess and DS0000061703.V279344.R01.S.doc 01/03/06 7. 8. YA10 YA11 06/02/06 01/03/06 9. 10. 11. YA11 YA14 YA14 01/03/06 01/04/06 01/04/06 12. YA19 01/03/06 13. YA19 01/03/06 14. YA19 01/05/06 15. YA19 01/03/06 16. YA20 01/03/06 17. YA20 01/03/06 Page 25 Raymond Avenue, 24 Version 5.1 18. YA22 22 19. YA23 13(6) 20. 21. 22 23. 24. 25. 26. YA24YA42 YA26 YA27 YA29 YA32 YA34 YA36 23(2)(d) 23(2)(d) 23(2)(b) 23(2)(n) 18(1)(c i) 19 Sch 2&4 18(2) 27. YA37 8 9 13(4c) 28. YA41YA42 take all possible action to ensure service users receive their prescribed medication when out of the home. The complaints procedure must be further developed to include details of the CSCI, and to state people making a complaint will not be victimised and that their complaint will be taken seriously. The policy must be kept under review. The adult protection policy must be further developed to include support organisations, and to contact social care and health if an allegation of abuse is made. The policy must be kept under review. Damaged plaster, decoration and furniture must be repaired or replaced. Decoration/repairs in some service users bedrooms must be undertaken. The bath panel in one ensuite must be repaired/replaced. Aids and adaptations must be provided as identified. The manager must ensure all mandatory training is provided at the required level. Records must evidence that robust recruitment practice is employed. Unmet from the last inspection. All staff must receive formal, recorded supervision at least bimonthly. The management of the home must be reviewed to ensure it is effective, and meets the needs of the service users. The fire risk assessment must be further developed to show how risks posed to individual service users will be met. DS0000061703.V279344.R01.S.doc 01/05/06 01/05/06 01/04/06 01/04/06 01/03/06 01/03/06 01/05/06 01/03/06 01/05/06 01/03/06 01/04/06 Raymond Avenue, 24 Version 5.1 Page 26 29. 30. YA42YA41 YA42 31. YA42 32. 33. YA42 YA42 An accident policy and procedure must be available in the home. 13(4)(b-c) Unmet from the last inspection. Risk Assessments must be developed for the premises and, staff. 13(4c) Screening for water bourne diseases must be undertaken, and a record of such maintained in the home. 13(4c) Food risk assessments must be dated, signed and kept under review 37 The CSCI must be notified of all reported incidents without undue delay. 13(4c) 01/03/06 01/04/06 01/04/06 01/03/06 06/02/06 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. 2. 3. 4. Refer to Standard YA1 YA18 YA41 YA42 Good Practice Recommendations It is recommended that information (including the service user guide) be provided in a more accessible format. It is recommended that storage for toiletries be provided in the ensuite bathrooms. It is recommended that the missing person policy be developed to notify Social Care and Health and to refer the reader to the service users individual risk assessments. It is strongly recommended that all risk assessments be reviewed at least six monthly. Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Raymond Avenue, 24 DS0000061703.V279344.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!