CARE HOME ADULTS 18-65
Yateley Avenue, 50 Great Barr Birmingham West Midlands B42 1JN Lead Inspector
Gerard Hammond Unannounced Inspection 09:45 2 & 5 December 2005
nd th Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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 Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Yateley Avenue, 50 Address Great Barr Birmingham West Midlands B42 1JN 0121 358 0462 0121 358 0462 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Residents must be aged under 65 years with a learning disability. The home can accommodate one named person over the age of 65. The home carries out a review at least six monthly to ensure the needs of the named individual continue to be met. 24th May 2005 Date of last inspection Brief Description of the Service: 50 Yateley Avenue is currently registered to provide accommodation, support and personal care for up to four adults with learning disabilities. The Home is run by Milbury Care Services and staffed 24 hours a day. It accommodates three male residents at present, having recently converted a shared room to a single bedroom. The house is situated in a quiet residential street in the Great Barr area of Birmingham, about five miles from the city centre. The property is semidetached and on a domestic scale, in keeping with other houses in the neighbourhood. The Home is well served by public transport, and there is a range of local amenities including shops, pubs, libraries and parks within walking distance. There are three single bedrooms in the house and a bathroom with w/c on both floors. Downstairs there is a separate lounge and dining room, kitchen and laundry. One of the single bedrooms is also situated on the ground floor. Upstairs there are two single bedrooms, and the staff sleep-in room. There is limited off-road parking on the front drive. To the rear of the property is a pleasant enclosed and private garden. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the second visit in the current inspection year. This report should be read in conjunction with the one written following the inspection carried out on 24 May 2005. The inspection took place over two visits. Direct observation and sample checking of records (including personal files, care plans, safety records and previous inspection reports) were used for the purposes of compiling this report. The Inspector met all three residents and formally interviewed the Manager, and met with two other staff members informally. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
Clear efforts have been made to meet requirements set at the time of the last inspection. The Statement of Purpose and Service User Guide, and also residents’ individual contracts, have been reviewed in order to reflect the current position, and updated accordingly. Attempts have been made to improve the activity opportunities available to people living in the house. Extra days have been negotiated for residents attending local colleges. Discussions have commenced with education services to further develop opportunities for maintaining or extending skill levels both at home and in community settings. Engaging another car driver on the care team has further enhanced the opportunities for residents to access facilities in the community. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 6 The number of people living in the house has reduced from four to three, and what was a shared bedroom has now been converted to a single room. The remaining residents are very happy with the new arrangements. Successful recruitment to vacant posts now means that the staff team is almost completely up to full complement. The Manager has maintained her efforts with regard to staff supervision, and this is now fully up to standard. 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. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 The Home’s Statement of Purpose and Service User Guide provide sufficient information to support judgements about the services provided. Residents each have an individual contract, as required. EVIDENCE: At the last inspection Standards 1, 2, 4 and 5 were assessed. Standards 2 and 4 were met in full. Requirements were made that the Statement of Purpose and residents’ individual contracts should be reviewed and updated, so that information is current and includes all necessary details. Both of these requirements have now been met. There have been no admissions since the time of the last inspection. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&9 Good work has been done in care plan development, and this should be continued and built upon. Residents’ personal goals should be reflected in their individual plans in such a way that the outcomes can be measured. Responsible risk taking is encouraged, to provide residents with opportunities for development and to enhance their independence, but risk assessments must be clearly linked to plans of care. EVIDENCE: Key Standards 6, 7 and 9 were all assessed at the time of the last inspection, together with Standard 8. Both Standard 7 and 8 were met in full on that occasion. Care plan development is very much a work in progress; it is clear that a lot of effort has gone into this and this should be commended. It is important that guidance in care plans about how people should be supported is very specific. One person’s plan referred to “support to travel”. This needs to say exactly what is required: for example, does this merely mean he has to be escorted, can he access a vehicle and use a seat belt independently, or does he need to be seated away from the driver, and so on?
Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 10 In another place, a component of this man’s plan was entitled “Sleeping”, but also contained information about what he does when he gets up in the morning. It might be that these should be separated, for example, into night and morning routines. This is only a small point, but the issue here is about information management: how would this be indexed so that any confusion is avoided, and a person would be able to go directly to the particular piece of information required, quickly and easily? Further thought needs to be given to goal setting. Current goals are quite generic, such as “maintain a safe environment” and “preserve personal dignity”. Goals should be specific and measurable: a key objective for setting goals is that they provide a “benchmark” against which the success of the care plan can be judged. The key question that should underpin each goal that is set should be “how can we demonstrate that this goal has been achieved, how will we measure that?” This will then form the basis for proper discussion when the care plan is reviewed. Clear links need to be established between care plans and risk assessments, as previously reported, so that the reader is naturally directed from one to the other. It is clear that appropriate consideration has been given to identifying hazards and devising control measures in many instances, so as to support residents’ independence, but this needs to be developed to make information more readily accessible. Simple cross-referencing and accurate indexing can support this effectively. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All of these standards were assessed at the time of the last inspection and met in full, with the exception of Standards 13 and 14, which were partially met. There have been some improvements to the opportunities people living in the house are now able to enjoy. There is now an additional car driver on the staff team. One resident attends college every weekday, and another has now increased his attendance at another local college from one to two days. The remaining resident is experiencing problems with his eyesight at present, and this has delayed taking up the possibility of another day’s activities for him. The Manager is also working with one of the colleges to promote new programmes aimed at developing individuals’ skills, and it is hoped that this can commence in the near future. It is clear that efforts are being made to develop new activity opportunities for the residents, and this is to be commended. The success of this will be assessed more fully at the next inspection.
Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: All of these key standards were assessed and met in full at the time of the last inspection. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not assessed on this occasion. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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): 25, 26 & 28 Residents’ rooms promote their independence, but some improvements are needed in general repair and maintenance. Shared spaces in the house are similarly now in need of some attention. EVIDENCE: All of these standards were assessed at the time of the last inspection. Since then, one of the residents has moved to another home because of deteriorating mobility. What was a shared room has now been converted to a single bedroom, so that all of the residents now have exclusive use of their own rooms. The two people who previously had to share are clearly very happy with the new arrangement, and this has made a positive impact on their personal independence. The windows in both upstairs bedrooms are in need of attention. Neither room has windows that close properly, and previous attempts to address the problem have only worked temporarily. The windows are old and should be replaced. The person using the rear bedroom has had to move his bed away from the window because of the draughts. The changes to the layout in this room could also be improved upon, by replacing the existing wardrobe with a fitted unit in the natural alcove. This would make much better use of the
Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 15 available space in the room, and give the resident more options. The downstairs bedroom would also benefit from redecoration. The lounge has been redecorated since the last inspection visit, but the other communal areas in the house are definitely showing signs of wear and tear. The dining room is in need of redecoration, and the carpets in the lounge, hall, stairs and landing are now very worn. A requirement that the wallpaper over the hall radiator should be repaired has not yet been met. In the same way, the units in the kitchen are well past their best, and bear the marks of having been repaired several times. Work surfaces, doors and drawers are all worn. It was also noted that the bath panel in the upstairs bathroom is in need of replacement. It is a requirement of this inspection that a copy of the home’s maintenance and renewal plan (Standard 24.12) is submitted to CSCI, detailing when outstanding maintenance and repairs will be dealt with. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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): 33, 34, 35 & 36 Improvements to the staffing complement have had a positive effect on the effectiveness of the care team. General recruitment policy and practice promotes the protection of people living in the house. An up to date training and development plan is required. Formal supervision has improved since the last inspection visit. EVIDENCE: The Manager advised that there is now only one vacant post on the staff team, and that this has been filled, subject to satisfactory CRB clearance. The personal file of one of the most recently appointed members of staff was sample checked. It was noted that all necessary documentation was in place, as required. A current staff development and training plan is now required, in order to assess accurately the training needs of the care team. This should show (for each member of staff) all training completed and qualifications gained, and highlight any gaps, including “refreshers”. The plan should indicate when outstanding training is scheduled, and who is to deliver it. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 17 It was reported at the time of the last inspection that the Manager was making clear efforts to bring formal supervision up to required standards. Sample checks of staff records indicate that this standard is now being met, and this should be commended. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 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): 39 & 42 The quality assurance and monitoring report for the Home is required, in order to judge whether or not residents’ views have been appropriately considered. General practice promotes the health, safety and welfare of people living in the house. EVIDENCE: Key standards were all assessed on the occasion of the last inspection visit. The Organisation’s report on the outcome of implementation of its quality assurance and monitoring systems should now be made available to interested parties. A copy should be submitted to CSCI. An application to CSCI to vary the conditions of registration in accordance with the current situation has been made to the Commission since this inspection visit. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 19 Safety records were sample checked. Tests of the fire alarm and emergency lighting systems have been carried out regularly, and fire-fighting equipment has been serviced. Fire evacuation drills have been conducted: the record should show the names of all those taking part. Water outlet and fridge and freezer temperatures have been checked and recorded regularly as required. Portable appliance testing has been carried out on electrical equipment, and the five-year hard wiring certificate is in date, as is the Landlord’s Gas Safety Certificate. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 20 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 3 X X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score X 2 3 X 2 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Yateley Avenue, 50 Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000016930.V271326.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) Requirement Further develop care plans and set targets with measurable outcomes. Ensure that records of reviews show who takes part and how decisions are made. Review risk assessments and cross reference to relevant care plan(s) Outstanding since 31/08/05 Review and improve the range of opportunities for residents to participate in the local community. (Partially met) Submit a current maintenance and renewal programme to CSCI for the fabric and decoration of the premises, taking particular account of items identified in the main body of this report relating to residents’ bedrooms and also the communal spaces in the house. Forward the current staff training and development plan, showing (for each member of staff) training completed and qualifications gained, highlighting gaps including refreshers, and indicating when outstanding training is
DS0000016930.V271326.R01.S.doc Timescale for action 28/02/06 2 YA9 13 (4) 28/02/06 3 YA13 16 (2m-n) 28/02/06 4 23 (2) 28/02/06 5 YA34 18 (1c) 28/02/06 Yateley Avenue, 50 Version 5.0 Page 22 scheduled. 6 YA39 24 (1-3) Implement the Organisations quality assurance systems and make the information available to interested parties. (Outstanding since 24/05/05) Forward a copy of this report to CSCI. 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA35 Good Practice Recommendations Consult with Community Nurse (LD) concerning development of Health Action Plans. Further develop training opportunities for staff in personcentred approaches, autism and augmented communication. Yateley Avenue, 50 DS0000016930.V271326.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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