Inspection on 06/06/06 for St Blaise Avenue (2)

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Blaise Avenue (2) 15/04/08

St Blaise Avenue (2) 20/02/06

St Blaise Avenue (2) 24/11/05

St Blaise Avenue (2) 13/01/05

St Blaise Avenue (2) 04/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 St Blaise Avenue (2) 2 St Blaise Avenue Bromley Kent BR1 3DA Lead Inspector Ann Wiseman Unannounced Inspection 6th June 2006 09:00 St Blaise Avenue (2) DS0000038974.V293725.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 St Blaise Avenue (2) DS0000038974.V293725.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. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Blaise Avenue (2) Address 2 St Blaise Avenue Bromley Kent BR1 3DA 020 8460 1851 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) Maxine.shawromley.gov.uk London Borough Bromley ** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered as a Care Home (CRH), with a service category of (PC) Care Home only, with a Service User Category of (LD) Learning Disability five (5), of both sexes, of which (LD(E)) Learning Disability over the age of 65, one (1). Registration is subject to the home complying with the Fire Precautions (Workplace) Regulations 1997 and the requirements as stated in the report submitted by the London Fire and Emergency Planning Unit dated the 21/07/03. 20th February 2006 2. Date of last inspection Brief Description of the Service: St Blaise is a two story semi-detached House in a residential road within walking distance of Bromley’s main shopping centre and is convenient for all local amenities and public transport. The home is part of the London Borough of Bromley’s care provision in the Learning Disability sector. The home provides support for five service users all whom have a learning disability; currently there are three male and two female service users. The home has its own manager and cares staff and will use Care Bank and Agency staff if the need arises. The Service Users in this home are supported in all their activities of day-today living and friends and families are encouraged to participate in the in the Service Users lives and leisure activities. The house has a garden to the front with parking for two cars and a good sized back garden. Policies, procedures and recruitment are organised through the central office of London Borough Of Bromley. Senior staff management and staff support are provided through Bromley Borough. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection, the Inspector arrived at St Blaise at 9am and spent five hours at the home. Two service users were at home with the Manager who facilitated the Inspection. The house was clean and well ordered and the Service Users were appropriately dressed. In the course of this inspection the Inspector was able to talk to Service Users, staff and two of the Service Users families by phone at a later date. User Surveys have been completed by the Service Users and the Commission also sent surveys to their families, two of which were returned. Paperwork examined was in order and Health and Safety checks looked at were in order. The house is still in need of redecoration and some minor repair work but the gardens have been tidied up and looks more inviting. What the service does well: 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. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 6 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 St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 7 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): All these standards were assessed during this Inspection Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. The home offers prospective Service Users the information they need to make an informed choice about the home and assessments are made. EVIDENCE: Prospective Service Users are given a copy of the Service User’s guide and Statement of Purpose to help them decide if they want to move into the house. Service Users files examined were found to contained copies of both, as well as contracts and a letter confirming that the service believes it can meet the needs of the Service User. The Manager confirmed that she would expect to receive an assessment for any new Service User on referral and that a new Service User will be given an opportunity to stay at the home before deciding to move in perminatly. The placement will be reviewed after six weeks. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 8 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): All standards in this section were assessed on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Service Users know that their assessed and changing needs and personal goals are reflected in their individual plans. EVIDENCE: Care Plans are detailed and are reviewed regularly. Person Centred Planning meetings are held annually and Service Users are supported to set new goals and review the progress of previous ones. The Service User will invite people to attend the meeting. Progress of the plan is recorded monthly and monitored. Service Users help to chose the menu and with the shopping. One of the Service Users travels independently to his day centre and other activities and likes to go to the local shops. All personal information is stored in the office in a locked filing cabinet. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 9 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): All areas of this area were examined during this visit. Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. The Service Users have some opportunities for personal development, have contact with family and friends, hold responsibilities within the house and are offered a varied diet. EVIDENCE: Service Users have the opportunity to attend a local day centre and each has a day off as a training day when staff aim to work on a 1-1 basis with them. During the training day Service Users are encouraged to tidy their bedroom and to do other domestic tasks. It is usual practice for one of the morning staff to go off duty at 9am once the Service Users have gone to the day centre. On the day of the Inspection one of the Service Users declined to go to the centre, this is not an unusual circumstance and sometimes more than one Service User will want to stay at home. This will make it unlikely that the planned 1-1 training sessions will happen with any regularity as the one staff St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 10 member will on duty will have to answer the phone and deal with callers to the house as well as attend to the needs of the other Service Users. The morning of the Inspection the Manager had to facilitate the Inspection, supervise two Service Users, one of which can be challenging, answerer the phone and deal with a call from contractors. One Service User travels independently, uses the local keep fit centre and would like to get out more, two others are very reluctant to take part in outings offered and prefer to stay at home. The activity sheet, that was introduced to monitor activities outside the house, shows that not many of the activities take place, the Manager felt that it was in some part due to the reluctance of some of the Service Users. User and Relative surveys returned indicated that they felt that not enough activities were on offer either in the house or out of it. One of the Service Users said that he would like to go to the pub, play some snooker, pitch and putt or to go swimming in his leisure time. It was also suggested that some in house activities were offered. It is recommended that ways are sought to encourage people to get out and about into the community and it is a Requirement that the registered Manager must establish and maintain a system for reviewing and improving the quality of care provided at the care home, in this instance to monitor that sufficient staff are employed to meet the needs of service users and to enable them to get out regularly and also to enable 1-1 training time to go ahead. Please see Requirement 1 and Recommendation 1. It is also recommended that in house activities are provided and that regular activity times are implemented. Please see Recommendation 2 St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 11 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): All standards were assed on this occasion. Quality in this outcome area good. This judgment had been made using available evidence including a visit to this service. Service Users receive personal care as they prefer, all Service Users have their health needs addressed and medication is stored and administered in a way that is promotes safe practice. EVIDENCE: Care plans are contemporary and reviewed regularly, needs are assessed and are of sufficient detail to enable the Service Users to receive personal care in a way that they would prefer and as required. All the Service Users are registered with the local doctor and personal files examined showed evidence that the support of other health care agencies were sought if the need arose, for example Speech and Language, Psychology or expert guidance is accessed thought the Bassett Centre and the Kent Association for the Blind. The homes previous failure to support a Service User to have appropriate dental or eye care has been a subject of a complaint by a family member; records show that this matter has been rectified and that all the Service Users have regular dental and eye care check ups. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 12 None of the Service Users are able to self medicate and all medication is stored in a locked medication cabinet fixed to the wall in the office, on examination the cabinet all the medication was found to be in order, there were no gaps on the recording sheet and there were photographs of the Service User in place. The home is the process of changing their current system of ordering, storing and dispensing medication. They will be using the system managed by Boots the Chemist, who will blister the medication, will undertake audits of the homes storage and administration of the medication and offer training. Service Users who’s health needs are change due to either age or illness are supported within the home and the Manager hopes that they will be able to continue to as far as the abilities and training of the staff team allow. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 13 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): Both Key Standards were addresses on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Complaints that have been received have been appropriately dealt with. EVIDENCE: The Inspector noticed during the last Inspection that one of the Service Users had made a complaint in writing and had given it to her key worker, the Inspector was able to track the complaint through the log book and complaints procedure. Since then the Service User has received a reply, measures have been implemented and she has expressed herself content with the outcome. Another complaint initiated by a relative regarding a Service User not receiving proper health care has also been addressed. The Inspector has contacted the Relative who expressed satisfaction with the outcome. No other complaints have been received either by the home or the Commission. All staff are subject to CRB checks before they are able to take up post and Protection of Vulnerable Adults training is offered to all staff. One of the Service Users has occasionally entered others rooms and hit out at the occupant. Guidelines and interventions are in place to help safeguard the safety of the Service Users from each other. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 14 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): Standards 24, 25, 27 and 30 were inspected on this occasion. Quality in this outcome area is adequate. This judgment had been made using available evidence including a visit to this service. The house is homely and comfortable but is in need of decoration in all of the communal areas and some of the bedrooms. Most of the bedrooms suit the needs and lifestyle of the Service Users and the home is clean and hygienic. EVIDENCE: The house has a homely and comfortable aspect in the main living areas, although the hallway is not very welcoming; there is a bookcase that has a few files and papers on it but is mainly empty. Copies of the registration details, fire procedures, insurance certificate and other notices are displayed on the walls and the fire safety equipment is prominent. All of which makes the entrance hall stark and office like, redecoration in a homely manner and some contemporary ornaments and pictures in this area would help give residents and visitors a warmer welcome. Please see Recommendation 3 The carpets have been cleaned since the last inspection. All of the Service Users bedrooms, except one, are well decorated and are individual to the occupant and reflects their chosen lifestyle. There are St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 15 ornaments and personal possessions around the room and posters, pictures and photos on the walls. The exception is a room that is occupied by a someone who can be challenging and will destroy furniture and remove items from the room if she decides she doesn’t want it. This Service User is the most recent person to have moved into the house. The room has the appearance of being empty, with hardly any personal belongings, no ornaments or pictures on the walls and toiletries are stored on top of the wardrobe to keep them out of reach. In addition the room itself is in need of decoration, the curtains are poorly hung and are on curtain tracks that have been put together from odds and ends as is the furniture. The Service User does have interests, such as music, and she does not remove her CD player from the room. The room must be decorated and her interests investigated and ways found to reflect them in the bedroom and to make it into a more comfortable and individualised area that the Service User may feel able to relax in and to develop ownership. Please see Requirement 2 The bathrooms and toilets all have the capability of being locked, but opened from the outside if someone requires assistance and they meet the needs of the Service Users. The house is mainly clean, although the poor state of the paint on the walls and woodwork must make it difficult to clean. All the bathrooms, Service User bedrooms and the kitchen were clean. Redecoration of the house has been a Recommendation of the last two Inspection Reports, the Manager has informed the Inspector that plans are being made to redecorate the home. This issue will now become a requirement. Please see Requirement 3 The house was having problems with a rat that has been seen in the garden. While the Inspector was in the home the environmental health workers set baited poison traps in the garden in areas that were out view and unlikely to accessed by any of the Service Users. They also left health and safety instructions; what to do if swallowed and details of the poison that the bait contained. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 16 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): Standards 31, 32, 34, 35 and 36 were examined during this Inspection Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Two Staff files were examined in detail on this occasion and found to be in order, the Service Users benefit from well supported, supervised staff that receive training that will help them to meet their needs. EVIDENCE: The staff files that were examined contained copies of the job description, job specification and evidence that CRB checks are carried out. The files also contained copied of the references obtained and indicates that the required recruitment policies and practices are in place. The home does not yet have the required percentage of qualified staff. The manager is working towards her NVQ4 and Registered Managers Award, one staff member has NVQ3 and another is working towards it, the home must continue to work towards compliance. Please see Requirement 4 As stated in a previous section it will be a Requirement that the registered Manager must establish and maintain a system for reviewing and improving the quality of care provided at the care home, in this instance to monitor that sufficient staff are employed to meet the needs of service users, enabling them to go out more and to enable 1-1 training time to go ahead when one or more St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 17 of the Service Users decide to stay at home instead of going to the day centre Please see Requirement 1 Training offered is varied and includes First Aid, Adult Protection, Physical Care, Food Hygiene, Visual awareness, Manual Handling, Managing Challenging Behaviour, Person Centred Planning, Medication Awareness, Supporting Communication, Working with Diversity, Fire safety and Dementia Care. There is evidence on file that staff attended training offered. Supervision notes seen indicate that formal supervision is given regularly. St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 18 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): Key Standards 37, 39 and 42 were inspected on this occasion. Quality in this outcome area is good. This judgment had been made using available evidence including a visit to this service. Under the care of the relatively new Manager the come is becoming well run and organised, User Surveys and meetings are used to underpin review and development of the home and the health, safety and the welfare of the Service Users are promoted. EVIDENCE: Over the three last Inspections it has become apparent that the house is becoming more organised and as a consequence better run. Policies and practice guidance has become ordered and easier to find, Service User files have had old and outdated papers removed, Care Plans have been updated and risk assessments have been reviewed. Staff files are now kept on site and were accessible to the Inspector. The Inspector was able to talk to two Service Users, two relatives and received user surveys from the Service Users and two family members. The Comments were generally positive about the service, some felt that there was a lack of St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 19 communication between the home and relatives, this has already been recognised and is being addressed by the Manager, some people felt that not enough leisure activities are being offered. The home has recently conducted it’s own User Survey and there are regular Service User Meetings, notes are take and issues that arise are discussed at Team Meetings. New Quarterly meetings have been introduced and relatives will be invited to meet with each other and staff to raise concerns and improve communication. The two comment cards from relatives both indicated that they did not have access to previous Inspection Reports, it is recommended that this and subsequent reports are made easily available to the relatives, and consideration should be given to informing the relatives when an Inspection has taken place, when the report has been received and what the outcomes were. Please see Recommendation 4 House Managers working in other homes run by Bromley Council take it in turn to carry out regulation 26 visits, during these visits Service Users are asked to give their opinion of the home and if they have any concerns. Each visit generates a report that is audited by the Registered Provider and a copy is sent to the Commission. The Regulation 26 visit also focuses on Health and Safety within the home. Reports received by the Commission are generally positive around these issues. H & S records that were randomly checked by the Inspector were found to be in order. Examination of the fridge found food that was not covered and open food packets and jars that did not indicate when it was opened. It is recommended that staff are reminded of the importance of good food hygiene. Please see Recommendation 5 During the Inspection the Manager was on duty on her own with two Service Users, one of which can be quite challenging. When asked about the lone working risk assessment, the Inspector was informed that it was generic to all staff and stated that one staff member could work alone with up to four Service Users. It is not good practice to have a generic risk assessments as all Service Users have different needs in supervision and all staff have different skills, capabilities and health needs. It is a requirement that lone working risk assessments are carried out for each staff member individually, the assessment must take into account their skills and experience as well as their health needs; for example if a staff member is diabetic, are her sugar levels well controlled? Also the differing needs of the Service Users should be considered; is the interaction between the group left at home stable, if challenging behaviour occurs will one staff member be sufficient to defuse the situation and offer support to the other Service Users etc. The risk assessment must also consider health and safety issues particularly relevant to working alone, such as St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 20 minimising the chance of a staff member or Service User having an accident. Please see Requirement 5 While working on her own with the two Service Users the Manager wore slip on shoes which the Inspector considers unsafe to wear in a working environment. They can be responsible for falls, especially on the stairs. It is recommended that guidelines are issued that outlines suitable clothing and footwear to wear at work. Please see Recommendation 6 St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 2 12 2 13 1 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 2 X St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 22 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 YA14 Regulation 24 Requirement The registered Manager must establish and maintain a system for reviewing and improving the quality of care provided at the care home, in this instance to monitor that sufficient staff are employed to meet the needs of service users and to enable those who want it, to go out and to enable 1-1 training time to go ahead. The room in question must be decorated and the Service Users interests investigated and ways found to reflect them in the bedroom and to make it into a more comfortable and individualised area that the Service User may feel able to relax in and to develop ownership. A program of redecoration must be developed be put into action. The home must continue to work towards compliance with the standard that requires 50 of care staff, excluding the Manager but including agency and bank workers shall attain NVQ2 or above. DS0000038974.V293725.R01.S.doc Timescale for action 04/10/06 2. YA25 23(2f) 04/10/06 3. 4. YA24 YA32 23(2d) 18(1a) 04/10/06 04/01/07 St Blaise Avenue (2) Version 5.1 Page 23 5. YA42 12 Lone working risk assessments are to be carried out for each staff member individually, that takes into account their skills and experience as well as their health needs and also the differing needs of the Service Users should be considered. The risk assessment must also consider health and safety issues particularly relevant to working alone. 04/10/06 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 YA14 YA14 YA24 YA43 Good Practice Recommendations It is recommended that ways are sought to encourage people to get out and about into the community more often consideration should be given be given to providing in house activities and setting up regular activity times. The hall way would benefit from a “Make over” to make it appear more inviting. It would be good practice if this and subsequent reports are made easily available to the relatives, and consideration should be given to informing the them when an Inspection has taken place, when the report has been received and what the outcomes were. It is recommended that staff are reminded of the importance of good food hygiene. It is recommended that suitable clothing guidelines is issued to all staff and implemented. 5. 6. YA42 YA42 St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 St Blaise Avenue (2) DS0000038974.V293725.R01.S.doc Version 5.1 Page 25 - 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. 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