Inspection on 08/08/05 for Raymond Avenue, 24

This inspection was carried out on 8th August 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 39 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 19/01/06

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 West Midlands B42 1LX Lead Inspector Alison Ridge Unannounced 8 August 2005 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 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 Stationary 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 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Raymond Avenue, 24 Address Great Barr Birmingham West Midlands B42 1LX 0121 357 0667 0121 357 0668 Platinum.care@btconnect.com Platinum Care Services Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Debbie Collins Care Home 5 Category(ies) of Younger People, Learning Disability (5) registration, with number of places Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate 5 service users under 65 for reasons of learning disability. Date of last inspection 15 February 2005 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 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 24 Raymond Avenue is a very new care home. This was the second unannounced visit to the home since it opened. One inspector undertook this visit over the afternoon and early evening of one day. Information was collected by talking with the men that live in the home and observing the care and support they receive. The inspector spoke to staff on duty and the deputy manager. Records about care, staffing and health and safety were assessed. A tour of the premises was undertaken. What the service does well: What has improved since the last inspection? Medication management has improved since the last inspection. The manager has started a new system that makes sure people get the right medicine at the right time. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 6 The records about people’s needs, and how these are to be met have improved. Some of the records had been written in a way that the men could look at and understand. 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 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 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 standard(s) X Standards not assessed at this inspection. EVIDENCE: The home has a stable service user group. None of these standards were assessed. Two previously made requirements regarding the development of the Statement of Purpose and Service Users Guide were not assessed. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 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 standard(s) 6,7,9,10 Some detailed plans that show how service users needs are to be met and risks managed have been developed. Other care documents require further development to ensure service users needs are consistently met in the way they prefer. Information about service users is handled confidentially. EVIDENCE: The individual plans of two of the men accommodated were assessed. The plans have been subject to significant development since the last inspection. One of the plans contained a lot of information about the service user, including, ”What other people say about me” and “About me”. It was not apparent how the information had been collected, or if this was direct from the service user. Neither of the plans sampled contained any elements of life or goal planning. This is something the home must work towards. The plans contained some detailed information about the service users needs, and how the home was setting out to meet these. The information required further development to ensure staff can provided care consistently, and that Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 10 service users preferences are ascertained and respected. Service users engage in behaviours and activities that present some risks. These had been identified by assessment. In some plans the measures to control the risk required further development. It was not always evident that the author of the document had a clear understanding of the purpose and function of risk assessments; it is recommended that the awareness training undertaken in the development of risk assessments be reviewed with staff. All information pertaining to service users was stored securely. No breaches of confidential information were noted. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 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 standard(s) 11,13,14,17 The number of opportunities to undertake activities were high, however the range and purpose of activities was not clear, and it was not evident that service users choose activities of interest to them. EVIDENCE: The service users accommodated at 24 Raymond Avenue do not all utilise the spoken word. Systems of communication that help service users express themselves, and enable staff to inform service users must be developed, and utilised in the home. Service users daily notes identify that community activities are being undertaken on a frequent basis. Most of the service users had accessed the community at least once each day in the period sampled. The range of activities offered was varied, and appropriate to the service users, however it was not apparent how the activities had been chosen, or if the purpose of the activity had been considered or explored. The manager reported that work is being undertaken with the multidisciplinary team to devlop systems that promote choice making. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 12 Many of the activities are undertaken as a group. The home should also consider the individual preferences and wishes of the service users accommodated. Service users returned from a picnic during the inspection. It appeared that this had been enjoyed. Service users were supported with another afternoon/ evening activity. Two service users the inspector spoke with reported enjoying the activities provided, and one service user reported he liked not being forced to do things he didn’t want to do. One service user reported favourably regarding a holiday he had recently been on. It was positive to hear that other service users have holidays planned. The menu showed a varied and interesting diet is planned. The stock of food available was of a good quality and very plentiful. The home had fresh salad, fruit and vegetables available. The records of food eaten included a variety of these items. Two service users the inspector spoke with regarding food reported very positively regarding this. The home had the appropriate foods to assist people meet their specific dietary requirements. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 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 standard(s) 18,19,20 Service users personal care needs are well met. Healthcare needs require greater planning and recording to evidence service users are receiving all healthcare and support required. EVIDENCE: The inspector met all five-service users and it was apparent they had all been supported to undertake personal care on the day of the inspection. During the visit service users were sensitively prompted or assisted, as they required. The service users had an individual supply of towels and toiletries in their room. Protective clothing for staff was stored discreetly to protect service users dignity. The home has worked with an occupational therapist to develop pictorial morning and evening routines for one service user. These were generally very detailed. The service users find routines and consistency very important, and some examples of the plans that need to be developed to be more specific regarding this was noted. The plans need to evidence that service users have been consulted, or how decisions regarding service users preferences have been reached. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 14 Service users had been supported to attend a variety of routine health care appointments. These had generally been well documented, and showed service users needs in this area had been met. The staff had completed a “Health Care Assessment”. These identified some specific, individual health care needs that had not been well planned for. The staff need to ensure service users are weighed, and a record of this maintained. Specific plans re the need to gain or loose weight must be developed if required for each service user. The Government White Paper “Valuing People” identified that all service users with a Learning Disability should have a Health Action plan by 2005. The manager must ensure that service users are supported with the development of such plans. All care records must be signed and dated. The service users accommodated all require support with some difficult to manage behaviour. One Reactive Management Plan (RMP) was assessed. This contained good proactive measures. It was not evident how some of the measures identified would be used. Examples included a statement that the service user responds better to a man. Evidence that male staff were always available, and the subsequent risk if this isn’t the case had not been explored. The final resort in the plan is to use the “Walk around technique”. No risk assessment regards the use of this in the home was available. The monitoring and evaluation of incidents requires review to ensure a full and robust record is made, which can be used in medical reviews, and to inform and direct care practice. It was not apparent in the records sampled that the Reactive management plan had been followed and it was concerning to read entries such as “Occasionally a bit agitated but calmer after PRN” and,” Was PRN’d” in the care notes. Medication management had significantly improved since the last inspection. The home usually utilises a monitored dose system (MDS). Confusion over medication ordering resulted in the system not being provided this month, and tablets were in bottles and packets. When audited a number of discrepancies between the number of tablets received, administered and available were noted. The home must ensure that systems to safeguard the administration of medication in the event of a MDS not being available are developed. Creams must be dated when opened and used or discarded within 28 days. Protocols for all as required medicines (PRN) must be available. These must be kept under review. Some service users are administered their medication in or with food. Both the ethical and medical issues surrounding the covert administartion of medicine must be explored and documented. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 15 The provision for administering medication when service users are on holiday or away from the home must be explored, and all possible action taken to ensure service users receive the prescribed dose. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 23 Service users present a risk to each other, and adequate strategies to protect service users were not in place. EVIDENCE: Regulation 37 notifications, and care records identify service users sometimes display behaviours that put other service users accommodated at risk of harm. The deputy manager reported the work being undertaken with one service user regards this. The records of incidents and as required medication (PRN) identified further occasions where one service user had tried, or successfully harmed other service users. The way in which the home had assessed this risk, and any strategies they had implemented were requested. The deputy manager gave some practical examples, but a written risk assessment or formal strategy was not availbale at the time of inspection. A copy of this has been forwarded to the CSCI, and is comprehensive. This area must be further explored, and both documents and practical strategies developed and implemented for the welfare of service users and to evidence that the home is taking all reasonable measures to ensure service users safety. It was positive to see that staff receive Adult Protection awareness training as part of the induction. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 17 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 standard(s) 24,25,26,27,28,29,30 Service users have been provided with a comfortable home with facilities provided to suit their needs and promote independence. Some of the furnishings, décor and cleanliness required attention to ensure the comfort and safety of service users. EVIDENCE: It was pleasing to see that the home has 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 proprietor identified this in the last regulation 26 visit to the home, and the inspector received verbal assurances from the manager that the matters would be addressed. In addition to these matters, it was identified that lampshades are required in the dining room and hallway. The hallway carpet requires a deep clean. The window frames in one service users bedroom did not appear to be sealed into the window frame securely. This must be explored and the required action taken. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 18 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. The pressure and temperature of water delivery was satisfactory in all but one of the ensuite baths inspected. One ensuite toilet seat needed replacement. A communal lounge, kitchen and relaxation area are provided for service users. It was observed that the grass in the garden required cutting. The inspector has previously raised concerns regarding the space available in the dining room, and the management of risk when all service users are eating a meal. The deputy manager reported some of the strategies adopted to reduce the risk. A risk assessment or written strategy was not availbale at the time of inspection, but has since been forwarded to the CSCI. Some environmental adaptations have been obtained which include a specialist chair, eating utensils, and a pressure sensor alarm. It was identified that items as identified by the Occupational Therapist also need to be further explored and obtained. Kylie pads were observed on chairs in communal areas. This is not respectful to the service users, and continence protection must be reviewed. It is required that protection be provided more discreetly, that service users receive a continence assessment, or chairs that meet service users needs be provided. Attention to cleaning kitchen cupboard and door fronts, cupboard shelves, and spills on the walls and the floor in the dining room was required. The home had hygienic hand wash and drying facilities at all communal sinks. Safe disposal facilities for clinical waste had been provided. Protective clothing had been provided, and was stored discreetly. Food hygiene was generally good. Two items that had passed the best before date were noted. Some meat that had been frozen, and been defrosted was in the fridge. It was not clear how long this had been defrosted, or for how long deemed fit to eat. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,36 Staff had a positive regard for service users, but records of recruitment and supervision did not show systems in place that would assure service users safety, or support staff in undertaking their role. EVIDENCE: The recruitment records of four staff were assessed. The files did not contain all documents required. Requirements to ensure that evidence of eligibility to work in the UK, Identification and the person’s job history for 10 years, are obtained have been made. One person under the age of 18 had been employed. The staff file did not contain a revised job description or risk assessment. No risk assessment regarding the impact of this person’s appointment on the staff team, or review of the minimum number of staff had been undertaken. The home responded promptly when this was brought to their attention. It was evident some advice had been sought regards this matter. Staff on duty at the time of inspection were knowledgeable about the service users, and how to meet their needs. Some very positive interactions between staff and service users were observed. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 20 The inspector observed one service user to enter the unstaffed office repeatedly over a fifteen-minute period. Staff on duty did not appear to be aware of the person’s where about’s or what they were doing. Two service users the inspector spoke with reported favourably regard the staff and their key worker. Only one of the staff files sampled was for an established member of the team. A record of one supervision was available. This was written in rough, and at the time of inspection did not evidence that a full supervision covering practice, training and welfare had been undertaken. The document was unsigned by either party. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 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 management arrangements of the home appear better defined and undertaken. Fire records evidence that the system is tested routinely. It was not apparent all call points in the home are tested in turn. This must be undertaken. The system has been serviced as required. The fire risk assessment identifies at point 3.5 that people in the home may not be able to evacuate. How this had been explored further was not evident. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 22 Risk assessments including management of challenging behaviour and the sexuality of service users must be developed. A general risk assessment for the premises must be developed. The risk assessment for food requires further development to incorporate the risks from purchasing, transporting, storing, preparing, cooking and discarding of food. The kitchen doorframe and door guard must be repaired and left in working order. Hazards to service users, including the sharp knife drawer being unlocked, and COSHH items being available under the sink, and in the unlocked laundry, and unlocked laundry COSHH cupboard were observed. Water temperatures had been tested and were within acceptable limits. The fridge/freezer temperature records did not evidence the fridge temperature was taken daily. This must be undertaken. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 4 2 2 3 2 2 Standard No 11 12 13 14 15 16 17 x x 2 2 x x 3 Standard No 31 32 33 34 35 36 Score x x 2 1 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Raymond Avenue, 24 Score 2 1 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4 Requirement The Statement of Purpose must be further developed to, contain details of the room sizes and how to make a complaint The Service users guide must be developed to include, A description of the support and facilities available, A description of the accomodation and communal space, Number of rooms available, Relevant qualifications of the manager and staff. The document must be produced in formats accessable to the service users. 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. Opportunity for service users to partake in Person Centred Planning as identified in the Government White Paper Valuing People must be provided. Plans must evidence consultation with the service user or their Timescale for action Not assessed at this inspection. Not assessed at this inspection. 2. YA1 5 3. YA6 15(1)(2) and 17 4. YA6 12(1)(a) 12(3) Not fully met from previous inspection. 1/10/05 1/10/05 5. YA6 12(1)(a) 12(1)(3) 1/10/05 Page 25 Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 6. YA9 and YA23 7. YA9 representative.(If this is not possible evidence as to how conclusions have been reached must be provided.) 13(4)(a-c) The risk service users pose to and 13(6) each other must be assessed and action taken to protect service users from harm or risk of harm 13(4)(a-c) Risk assessments must be developed that fully address and underpin the risks service users take and are exposed to. 12(1)(a) and 12(4)(b) 12(3) and 16(2)(mn) 12(1)(a) and 15 Communication systems as assessed as being required by service users must be provided, and in operation in the home. Systems that evidence how activities are chosen and planned must be developed. Care and support plans that detail the service users preferences and needs regarding personal care must be developed. Opportunity for weight monitoring must be offered to service users. Plans to underpin nutritional needs must be developed if required. All specialist healthcare appointments must be offered and evidenced. Action required by members of the Multi Disciplinary team must be undertaken. Care plans that underpin how additional healthcare needs including epilepsy and behaviour must be developed. Service users must be supported in the development of Health Action plans All care records must be signed and dated. 8. YA11 Not fully met from previous inspection. 1/9/05 Not fully met from previous inspection. 19/9/05 1/10/05 9. 10. YA14 YA18 1/11/05 Not fully met from previous inspection. 1/10/05 1/10/05 11. YA19 12(1)(a) and 15 12. YA19 12(1)(a) and 13(1)(b) 1/10/05 13. YA19 12(1)(a) 14. 15. YA19 YA19 12(1)(a) and 12(3) 12(1)(a) and 17 Not fully met from previous inspection. 1/9/05 1/11/05 1/9/05 Page 26 Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 16. YA19 17. YA20 12(1)(a) and 13(4)(c) and 13(6) 13(2) 18. YA20 13(2) 19. YA20 13(2) 20. YA24 and YA42 23(2)(d) 21. YA24 13(6) and 23(2)(e) Behaviour management plans that contain proactive and reactive measures must be developed. Medication management must be developed to ensure that, protocols for all as required medicines are provided. Stock checks of medicines not blister packed must be undertaken regularly. Ethical and clinical issues re administration of medication in food must be explored and documented. The home must risk assess and take all possible action to ensure service users receive their prescribed medication when out of the home. Damaged plaster, decoration and furniture must be repaired or replaced. The kitchen door frame and door guard must be returned to full operation. The provision of dining space must be explored, risk assessed and systems to ensure the safety of service users and staff at meal times undertaken. Lampshades must be provided in the dining room and hallway A deepclean of the hallway carpet must be undertaken. 1/10/05 Unmet from last inspection. 1/10/05 1/11/05 1/10/05 22. YA24 16(2)(c ) 23. YA26 13(4)(b-c) The fitting of the window frames and in one bedroom must be 23(2)(b) reviewed to ensure they are secure. 23(2)(d) Decoration/repairs in some service users bedrooms must be undertaken. 24. YA26 Provider to give timescale with response to report. Evidence of requirment being met provided with action plan. Provider to give timescales in response to report. Provider to give timescales in response to report. Provider to give timescales in response to report. Page 27 Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 25. YA27 23(2)(j) Water pressure in one ensuite bathroom must be further increased. 26. 27. YA29 YA29 28. YA30 29. YA30 and YA42 30. YA32 31. YA34 32. 33. 34. 35. YA36 YA42 YA42 YA42 Aids and adaptations must be provided as identified. 12(4)(a) Incontinence protection must be reviewed to ensure that service users needs are met, and their dignity respected. 23(2)(d) Cleaning of kitchen cupboards and drawer fronts, kitchen cupboard shelves, dining room walls and floors must be undertaken. 23(5) and Food must be used or discarded 13(3) on or before the best before date. The fridge/freezer temperature must be taken daily and a record of such maintained. The use by date of items previously frozen must be recorded. 18(1)(a) A revised job description and and 19 review and risk assessment and 18(2) regards the minimum number of staff provided must be undertaken re staff under the age of 18. 19 and 17 Recruitment records as detailed Schedule in schedule 2 of the Care Homes 2 and 4 regulations must be available for all staff that work in the home. 18(2) All staff must receive formal , recorded supervision at least bimonthly. 23(4)(c All fire call points must be tested )(iv) in turn, and a record of such maintained. 13(4)(a-c) Control measures for matters identified in Risk Assesments must be developed. 13(4)(b-c) Risk Assessments must be developed for the premises and, staff and further developed re food hygiene. E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc 23(2)(n) Provider to give timescales in response to report. 1/10/05 19/9/05 19/9/05 19/9/05 1/9/05 Unmet from last inspection. 1/9/05 1/10/05 1/9/05 19/09/05 1/10/05 Raymond Avenue, 24 Version 1.40 Page 28 36. YA42 13(4)(b-c) Items that present a hazard to service users health and safety must be risk assessed and action taken to protect service users from harm 19/9/05 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 YA9 Good Practice Recommendations It is recommended that staff receive awareness training on the purpose and development of risk assessments. Raymond Avenue, 24 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 29 Commission for Social Care Inspection Birmingham & Solihull Local 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 E54 S61703 Raymond Avenue 24 V243618 080805 Stage 4.doc Version 1.40 Page 30 - 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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