Inspection on 20/08/04 for Reinwood Avenue

Care Homes For Adults (18 ­ 65)Reinwood Avenue26 Reinwood Avenue Leeds West Yorkshire LS8 3DPAnnounced Inspection20th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Reinwood Avenue Address 26 Reinwood Avenue, Leeds, West Yorkshire, LS8 3DP Email address Tel No: 0113 273 0083 Fax No: 0113 2730083Name of registered provider(s)/company (if applicable) Community Integrated Care Name of registered manager (if applicable) Mrs Lynda Whitehead Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number B080000369 Date first registered 2nd July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 9th December 2003 Yes NO 03/11/03 If Yes refer to Part CReinwood AvenuePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 320th August 2004 10:00 am Kathryn SmithID Code071366Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionReinwood AvenuePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementReinwood AvenuePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Reinwood Avenue. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Reinwood AvenuePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The home is run by Community Integrated Care (CIC) and provides care and accommodation for up to three people with a learning disability, the house itself is owned by South Yorkshire Housing Association. It is situated in the pleasant area of Oakwood, accessed easily via the A58 by car, and a regular bus service runs past the end of the road from Leeds City Centre. Local amenities close by include shops, pubs, a church, a sports centre, GP, chemist and a hairdressers. The home is a bungalow and so is managed over one floor, and provides pleasant well maintained accommodation, with a good-sized garden to the rear producing fruit and vegetables. The home also has chickens in the back garden that provide eggs for the home.Reinwood AvenuePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was carried out over one day by one inspector. Reinwood Avenue was found to be pleasant and welcoming. The management and service users were all very accommodating and helpful throughout the inspection process. Choice of Home ( Standards 1 ­ 5) Two of these standards were assessed, these were not quite met. The service user guide is prepared in an appropriate format, however the key contract terms are still missing from this. A contract is provided to each service user, whilst some changes have been made to this, the arrangements for reviewing needs and progress, and updating the service user plan has still not been added. Individual Needs and Choices (Standards 6 ­ 10) Four of these standards were assessed, and these were all met. Each service user has an allocated key worker and a service user plan which is generated through the assessment process, the plan is reviewed monthly by the manager, and a multi disciplinary review is held annually. Risk assessments are carried out on all areas of perceived risk for each service user; these are reviewed annually or sooner as required. Lifestyle (Standards 11 ­ 17) Five of these standards were assessed and these were all met. Service users are supported to learn practical life skills and these are outlined in their plan of care and include housekeeping tasks such as cleaning, cooking and washing according to their assessed ability. All of the current service users attend a day centres, or day services regularly; these day centres offer support based on the assessment of the service user. Personal and Healthcare Support (Standards 18 ­ 21) Two of these standards were assessed and these were both met. All service users currently use the same GP, however the manager informed me that they have the choice of retaining their own GP or choosing an alternative. The manager provides training in medication to staff every six months, in addition all staff have recently attended a three-month distance learning training course on medication run by the local college. Concerns, Complaints and Protection (Standards 22-23) One of these standards was assessed, and this was met. The home has chosen to adopt the adult protection procedure of the Leeds Multi Agency Adult Protection Procedure. The registered manager informed me that all staff have had access to this procedure and are familiar with its contents. Reinwood Avenue Page 6 Environment (Standards 24 ­ 30) Four of these standards were assessed and these were met The home is well presented, clean and welcoming and the living space for each service user meets the required 14.1sq m. On the day of the inspection the home was free from offensive odours and provided sufficient light, heating and ventilation. Provision has been made for an alternative office area, some service users still use this area to watch television or for company, though files are kept locked away and some are still locked in the sleep in room, if staff wish to make private phone calls they use the sleep in room. Staffing (Standards 31 ­ 36) Three of these standards were assessed and all were met, one was in fact exceeded. Two staff members are currently undertaking NVQ level 3 in promoting independence; the manager is now a qualified assessor. A rota was examined, which appeared to provide satisfactory cover, holidays are being covered by overtime or bank staff. The manager aims to offer staff supervision monthly, this amounts to in excess of six supervisions per year, the wall chart shows the dates for this as evidence, this demonstrates commendable practice. Management of the home (Standards 37 ­ 43) Four of these standards were assessed, and these were all met. The registered manager has worked in care since 1991, and has worked with service users with learning difficulties since 1998. She has an NVQ 2 and 3 in care, and is currently working towards her registered managers award (NVQ 4). The manager appears to communicate with a clear sense of direction and displayed good leadership skills.Reinwood AvenuePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 5 YA1 The service user guide must have key contract terms. 01/12/03Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 YA5 The terms and conditions should be modified to include arrangements for reviewing needs and progress, and updating the service user plan.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Reinwood AvenuePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action None from this InspectionRECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * None from this Inspection * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Reinwood AvenuePage 9 PART BINSPECTION METHODS & FINDINGSYES YES YES YES YES YES YES NO YES NO YES NO YES YES NO NO NO YES NO YES 2 0 0 NA YES YES YES 6 0 20/08/04 10:00 3The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)Reinwood AvenuePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Reinwood AvenuePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 2 Key findings/Evidence Standard met? The service user guide is prepared in an appropriate format, however the key contract terms are still missing from this. Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Reinwood AvenuePage 12 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? A contract is provided to each service user, whilst some changes have been made to this, the arrangements for reviewing needs and progress, and updating the service user plan has still not been added.Reinwood AvenuePage 13 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has an allocated key worker and a service user plan which is generated through the assessment process, the plan is reviewed monthly by the manager, and a multi disciplinary review is held annually. The plan sets out current and anticipated specialist requirements where appropriate, and is drawn up with involvement of the service user. The service user is involved in the allocation of the key worker as far as possible. The home now uses a person centred planning approach, for the service user plans, an example of this was inspected and appeared to be a working document covering all areas of assessed need. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service users are given information and support to make decisions about their own lives as far as they are able. Staff help service users to find and participate in a local advocacy services. The registered manager stated that service users are currently unable to manage their own finances completely, however, they are given support and guidance to handle small amounts of their own money.Reinwood AvenuePage 14 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Service users are given the opportunity to participate in independent advocacy services that may be used to influence key decisions within the home. The home has in the past held service user meetings, though dont at present as the service users do not feel able to contribute. The manager feels that this is an area where service users are given constant involvement on a one to one basis. In addition relatives are given the opportunity to participate, service users are involved in assisting with housework as their abilities allow.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Risk assessments are carried out on all areas of perceived risk for each service user, these are reviewed annually or sooner as required. The risk assessment process encourages service users to be independent as far as possible. Various risk assessments were inspected and found to be reviewed regularly. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Reinwood AvenuePage 15 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users are supported to learn practical life skills and these are outlined in their plan of care and include housekeeping tasks such as cleaning, cooking and washing according to their assessed ability. The current service users do not have an interest in religion, however the registered manager informed me that if they were religious they would be supported to fulfil their spiritual needs. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? All of the current service users attend a day centres, or day services regularly; these day centres offer support based on the assessment of the service user. Service users are given the opportunity to attend college courses though these are not being utilised at present.Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? Standard not assessed on this occasion.0Reinwood AvenuePage 16 Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The home has a policy relating to visitors and family and friends contained within the service user guide. Service users have regular contact with their families and friends. Families visit service users in the home, and service users also stay with their families when they wish. Service users can choose whom and when they see and can have visitors in the privacy of their own rooms if they wish.Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? The registered manager informed me that all staff knock before they enter the home, and before they enter service users bedrooms, this was observed on the day of the inspection and is also stated in the service user guide. All bedroom doors are lockable, service users are offered their own keys, though at the moment have declined this offer. Service users are offered their own mail to open, and are given staff support if required. Service users are free to choose when to be alone and when to have company, and staff make a point of asking service users what their preferred form of address is prior to admission. Staff were observed interacting freely with service users, and not exclusively with each other. Smoking rules are stated in the homes policies. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Meal times are flexible, service users can choose when and where to eat. In addition service users can choose what to eat and so on occasion each service user can be eating something different at one meal time. The staff provide a cooked meal at least once per day usually on an evening, and service users are fully involved in choosing this.Reinwood AvenuePage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 103 Key findings/Evidence Standard met? All service users currently use the same GP, however the manager informed me that they have the choice of retaining their own GP or choosing an alternative. Occasionally the GP will visit the home, at other times staff will accompany service users to the surgery. The accident book was inspected and found to be in order and up to date. The registered manager is aware of the new requirements regarding data protection, and is advised to seek guidance on this.Reinwood AvenuePage 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The home has a medication policy kept both in the medication file, and in the policy manual. The manager provides training in medication to staff every six months, in addition all staff have recently attended a three-month distance learning training course on medication run by the local college. Medication is administered through the use of blister packs provided by Boots. Medication records were examined and found to be up to date and accurate. None of the service users are self-medicating, and the home does not have any controlled drugs. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Reinwood AvenuePage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Standard not assessed on this occasion. X X X X X X X Standard met? 0Reinwood AvenuePage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home has chosen to adopt the adult protection procedure of the Leeds Multi Agency Adult Protection Procedure. The registered manager informed me that all staff have had access to this procedure and are familiar with its contents. The manager has had no cause to implement this procedure.Reinwood AvenuePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is well presented, clean and welcoming and the living space for each service user meets the required 14.1sq m. On the day of the inspection the home was free from offensive odours and provided sufficient light, heating and ventilation. All furnishings and fittings appear to be good quality, domestic and in keeping with the style of the rooms. One of the bedrooms and the hall has been decorated since the previous inspection, and the kitchen worktop has been replaced as it had cracked. One of the lounge areas is now used as an office, though service users are still free to wander in to watch television or for company.Reinwood AvenuePage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 3 0 0 0 3 00 0 0 03 Key findings/Evidence Standard met? All service users bedrooms provide in excess of 12sq m and all service users have a single bedroom.Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Standard not assessed on this occasion. Standard met? 0Reinwood AvenuePage 23 Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The communal space meets the required 4.1 sq m per service user and there is a goodsized garden for use by all service users. There is no private area for visitors, consultations or treatment, though provision is made where this is required. Provision has been made for an alternative office area, some service users still use this area to watch television or for company, though files are kept locked away and some are still locked in the sleep in room, if staff wish to make private phone calls they use the sleep in room. Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home had no offensive odours on the day of inspection and appeared clean and hygienic. Laundry facilities are sited away from areas containing food. There are handwashing facilities in the laundry and kitchen and in each of the bathrooms and bedrooms. Laundry walls and floors were impermeable and cleanable. Policies were available for the control of infection.Reinwood AvenuePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Two staff members are currently undertaking NVQ level 3 in promoting independence; the manager is now a qualified assessor. Two further staff members intend to start NVQ when the first two have finished. Staff demonstrated knowledge and awareness of service users specific conditions and needs.Reinwood AvenuePage 25 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X003 Key findings/Evidence Standard met? A rota was examined, which appeared to provide satisfactory cover, holidays are being covered by overtime or bank staff. The home currently has a 15 hour vacancy which is being advertised.Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Reinwood Avenue Page 26 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 4 Key findings/Evidence Standard met? The manager aims to offer staff supervision monthly, this amounts to in excess of six supervisions per year, the wall chart shows the dates for this as evidence, this demonstrates commendable practice. Staff are offered personal development plans six monthly, these are used to identify further needs either training or service user based. The manager informed me that staff are given a copy of the grievance and disciplinary procedure on commencement of employment.Reinwood AvenuePage 27 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? The registered manager has worked in care since 1991, and has worked with service users with learning difficulties since 1998. She has an NVQ 2 and 3 in care, and is currently working towards her registered managers award (NVQ 4). The manager was given a job description when she applied for the post and is aware of her duties and responsibilities. Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The home presents a very open and inclusive atmosphere, service users and staff wandered in and out of the office for advice and company regularly throughout the inspection. The manager appears to communicate with a clear sense of direction and displayed good leadership skills. Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Reinwood AvenuePage 28 Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? Standard not assessed on this occasion. Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? Standard not assessed on this occasion. Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The home has two comprehensive fire manuals detailing procedures, staff training, fire risk assessments and regular checks on alarms, emergency lighting and fire fighting equipment. General risk assessments have been carried out on various parts of the home, these are dated and reviewed annually. Coshh risk assessments are carried out and checks are done weekly. Safe assured catering systems are adopted and files were available.. The staff carrry out a health and safety check each week, this is recorded and copies are sent to the head office and the local office. The home has health and safety policies covering all areas, all staff undertake first aid training every three years and a first aid box is kept in the home. The home has an accident book which is kept up to date and the registered manager is aware of notifiable incidents. Two staff have recently doing a course on facilitating moving and handling training, this training is then delivered in house to other staff members. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? The manager informed me that the organisation has a business and financial plan for the home, budgeting systems are in place, and the home has adequate insurance cover. Lines of accountability appear to be understood by staff and service users.Reinwood AvenuePage 29 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Public reportsKathryn Smith Chris Picking 13th October 2004Signature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.Reinwood AvenuePage 30 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 20th August 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleReinwood AvenuePage 31 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office.Reinwood AvenuePage 32 D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Reinwood AvenuePage 33 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Charles Eggleston of Reinwood Avenue confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Reinwood AvenuePage 34 Reinwood Avenue / 20th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000001401.V171469.R01© This report may only be used in its entirety. 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