Inspection on 24/05/05 for 50 Yateley Avenue

This inspection was carried out on 24th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

50 Yateley Avenue 14/03/08

50 Yateley Avenue 07/03/07

50 Yateley Avenue 02/12/05

50 Yateley Avenue 14/10/04

50 Yateley Avenue 11/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Yateley Avenue, 50 50 Yateley Avenue Great Barr Birmingham B42 1JN Lead Inspector Gerard Hammond Announced 24 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Yateley Avenue, 50 Address Great Barr Birmingham B42 1JN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 358 0462 0121 358 0462 Milbury Care Services Ltd Care Home 4 Category(ies) of Learning Disability registration, with number of places Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years with a learning disability. 2. The home can accommodate one named person over the age of 65. 3. The home carries out a review at least six monthly to ensure the needs of the named individual continue to be met.. Date of last inspection 14 October 2004 Brief Description of the Service: 50 Yateley Avenue is registered to provide accommodation, support and personal care for four adults with learning disabilities. The Home is run by Milbury Care Services and staffed 24 hours a day. 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 two single bedrooms and one shared bedroom 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 is the shared room and other single bedroom, 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 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Direct observation and sampling of records (including personal files, care plans and safety records) was undertaken for the purposes of compiling this report. The Inspector met all four residents. A formal interview was conducted with the Manager, and two other staff members, the Organisation’s Service Manager, and a visiting health professional were also seen. In addition to information provided in response to the pre-inspection questionnaire, feedback was received from relatives and the G.P. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be developed so that it is possible to measure improvements and progress. This can be done by setting some goals, and then looking to see what has worked and what needs to be changed. Work needs doing to extend the opportunities people have to be part of the local community, and improve the quality of their leisure time. Vacant posts should be filled with permanent members of staff, so that less bank and agency staff are needed. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 6 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 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4 & 5 The Statement of Purpose and Service User Guide provide most of the information needed to make an informed choice about services provided, and this is reinforced by assessment and admission procedures. Individual contracts need to be updated to provide clear and current information. EVIDENCE: The Statement of Purpose and Service User Guide contain most of the information required, and attempts have been made to present this in a more accessible format through the use of pictures and symbols. However, the requirement made at the last inspection to include specific information about the shared room remains outstanding. There have been no new admissions in the last seven years, and most of the current residents have lived in the house since 1991. Admission procedures cover assessment and the opportunity for “trial visits” appropriately, so that any future decisions about accessing this service can be properly informed. Individual contracts should be reviewed so that they show clearly the current cost of the service and indicate specifically residents’ and other parties’ contributions and charges. Ideally, contracts should be signed by the individual concerned, where possible. In cases where individuals are unable to sign, the Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 9 opportunity for the contract to be countersigned by a relative, friend or independent third party should be seen as standard good practice. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 & 9 Individual plans need some development to set goals, so that these can be measured in the future. There has been some positive work done to promote person-centred approaches and present information in more accessible ways. Staff support residents to make choices and decisions about day-to-day things in their lives. People are supported to take responsible risks, but some work needs to be done on the ways in which risks are assessed and how this information is presented. EVIDENCE: Some commendable work has been undertaken in recent months to present information about individuals’ needs in an accessible and user-friendly way. Each person has a “Communication Passport” containing some information about how he communicates, together with preferred routines and general likes and dislikes. However, it is important that information presented in this way is consistent with, and underpinned by, comprehensive statements of need, appropriate risk assessments and detailed care plans. In one instance, an individual’s “preferred getting up time” was shown differently in four separate places on his personal file! Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 11 Care plans should seek to set targets with outcomes that can be measured. These can subsequently be evaluated at review, and amended or continued as appropriate. Reviews need to indicate who takes part and how decisions are made. Members of staff actively encourage residents to take responsibility for as many things are they are able, within their individual capabilities. They seek to promote choice wherever possible, and respect the choices people make. Individuals’ communication difficulties place some restrictions on how this is put into practice. Where possible, attempts are made to overcome this, for example, through the use of pictorial aids to support making choices for meals and food shopping. Some work is required on risk assessments to ensure that they are up to date and reflect individuals’ current support needs. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. If an index is used, it must be accurate and up to date. One of the outcomes for completing risk assessments and care plans should be that the finished article is a simple and effective working document, in which essential information can be easily found. A senior member of the care team has recently undertaken training in personcentred approaches. This positive development needs to be built upon to support the future development of care planning with the individuals concerned. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16 & 17 Work needs to be done to develop the range and quality of activities available to residents in order to promote their personal development, improve their opportunities to participate in the life of the local community and enjoy their leisure time more fully. Staff respect peoples’ rights and seek to promote their independence. Residents enjoy a healthy and nutritious diet and exercise choice about what they eat. Arrangements for meals are flexible and take account of residents’ preferences. EVIDENCE: Records seen and direct observations made indicate that people do have some opportunities for social, emotional, communication and skill development. Some thought now needs to be given about how to move this forward. An analysis of these four areas for each person living in the house would be an appropriate place to start. Indicate specifically for each individual what opportunities for development have been enjoyed in these areas: these should have clear links to individuals’ care plans. Identify specific areas to be worked Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 13 on and set some targets. This should be done in conjunction with the general review of activity programmes referred to below. People attend college placements and local day centres, but little or no information about these activities is evident on their personal files. Activities programmes need to be an integral part of individuals’ care packages, and not something that goes on “over there somewhere”. Similarly, people do go out into the community, but as was observed at the time of the last inspection, this appears limited to walks, shopping, going to the barbers and occasional cinema or pub visits. Access to the community has also been restricted by the fact that there has only been one member of staff able to drive the Home’s car. As the residents all contribute financially for the provision of a vehicle, it has to be asked whether they are receiving value for money. However, it has to be acknowledged that attempts are being made to increase the number of drivers available, so that better use might be made of the car. A requirement was made at the last inspection that a review of opportunities for people to be part of their local community should be undertaken. Some work has been done on this but the situation has not been helped by current staff shortages. Nonetheless, this requirement is outstanding, and the situation needs to be addressed. In keeping with comments made above, a systematic analysis of individuals’ activities needs to be done to establish a baseline. This should involve a clear statement of what activities people have actually taken part in over the past 3-6 months, so that a true picture can be gained of the range and quality of opportunities enjoyed. Judgements need to be made about the purpose of scheduled activities in order to evaluate their effectiveness. This means being clear about whether, for example, an activity is meant to be an opportunity to acquire or develop a particular skill, whether its purpose is therapeutic, or just to have fun – or a combination of any or all of these. It is only by being clear about these things, and setting targets as part of individuals’ overall care planning (and subsequently reviewing them) that their true worth can be evaluated. Residents are supported to maintain links with family and friends where this is possible. Positive feedback was received from two relatives prior to this announced inspection. Direct observation confirmed that staff respect individuals’ rights to make choices and that they seek to involve people in the daily routines of the house. The food cupboards, fridge and freezer were well stocked, and meals and menus were seen to more than satisfactory. Staff and residents generally eat together in a relaxed manner, though one individual sometimes opts to take his meals alone and this is respected. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, & 20 Personal support is delivered in accordance with residents’ preferences and requirements. Health needs are generally appropriately met, and positive action is being taken to make further improvement. Practices relating to the storage and administration of medication are generally satisfactory. EVIDENCE: Residents and staff appear to enjoy a good general rapport. Support is given in a warm and friendly manner, and staff were seen to be polite, considerate, patient and respectful, as appropriate. Records show that referrals are made to healthcare professionals as and when required. A new format for Health Action Planning has been introduced recently. Good work has been done in seeking to identify and systematically record individuals’ health needs. This should now be built on so that the document moves from being a statement of need to a planning and monitoring tool. It may be that this is an opportune time to engage with the local Community Nurse (Learning Disability) Service in order to move this forward. At the same time, the medical notes file held for each resident should be Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 15 reviewed. These records were seen to contain substantial amounts of old or unrelated material, which should be destroyed or archived as appropriate. A visiting podiatrist was interviewed on the day of the inspection. She indicated that she is always well received, and that staff work co-operatively to support treatment programmes. The accident book was seen: some reports were still in the book. These should be filed on individuals’ personal records (with an indication on the counterfoil as to their location) in order to comply with current data protection legislation. It was also noted that a report to CSCI, as required under Regulation 37, had not been completed in all appropriate cases. Action must be taken to ensure that this requirement is met in future. None of the residents are able to manage their own medication. Previous inspection reports have indicated that administration systems meet required standards. Medicines were seen to be stored appropriately in a secure location. A random audit of stocks held in respect of two individuals revealed no discrepancies, and there were no gaps on the administration record. Creams and lotions were labelled with the date of opening. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Residents’ communication difficulties make it difficult to assess fully their satisfaction with regard to whether or not their views are listened to and acted on. However, measures are in place seeking to take account of what people think as much as possible. The organisation’s policies and procedures with regard to adult protection are adequate. All staff have a responsibility to ensure that they are implemented effectively and correctly. There are some concerns about the amount of time taken to complete the process in a recent adult protection investigation. EVIDENCE: The complaints book was seen. No complaints have been received since the last inspection. Individuals’ communication difficulties make it difficult to assess fully whether or not they feel that their concerns are listened to and acted upon. Residents are reliant on staff that know them well to pick up on cues and clues as to whether or not they are happy. Conversations with members of staff indicated that they have a good knowledge of individuals’ ways, and are sensitive to people’s non-verbal communication. There are documents available within the organisation, designed to guide staff in seeking residents’ views. These are entitled “Let us know what you think” and “Questions about your house”. None of the people living in this house would be able to complete these independently. They were in place on one of the personal files checked, but there were a number of significant omissions that jeopardised their effectiveness as useful tools. It may be that staff need support in order to use these properly. The good work already done in making these resources available should not be lost through ineffective use. Feedback Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 17 was received from two residents’ families, expressing general satisfaction with the service received by their relative. At the time of the last inspection, an adult protection investigation was in progress. This matter is still not yet fully resolved as a decision has to be reached concerning a referral for inclusion on the POVA list. The amount of time taken to bring this matter to a conclusion is cause for some concern. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 & 30 The environment at 50 Yateley Avenue is generally comfortable, homely and safe. There are concerns about the suitability of the shared bedroom in meeting the needs and promoting the independence of the occupants. This is not an issue for the residents who have single rooms. Bathrooms and toilets are sufficiently private and currently meet individuals’ needs. Residents are able to make good use of the shared spaces within the house. Equipment necessary for promoting individuals’ levels of independence is available. The house is kept clean and good standards of hygiene maintained. EVIDENCE: The house has a generally comfortable, “lived in,” warm and homely feel about it. A small number of minor items were in need of attention, and these are detailed at the end of this report. The lounge is now in need of redecoration. Bedrooms are individual in style, and there is plenty of evidence of personal effects and possessions. People can do their own thing, watching television or listening to music, and so on, whenever they wish. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 19 The shared room remains a cause for concern. The room is split by means of a permanent partition, which accommodates wardrobe space and washbasins. This affords the two men who share the room a degree of privacy, but reduces the available floor space to well below the current standard required. The natural light available in one half of the room is very limited, and the resident who occupies this area raised this concern explicitly. A requirement has been made that options for improving the light into the room are explored expediently. There is a bathroom and toilet on both floors. The ground floor bathroom has a second door leading directly into the bedroom of one of the residents. This door is only unlocked during the night for his use, as all other sleeping accommodation is upstairs. People living in the house need to be fairly mobile in order to use the bathing facilities independently. Assisted bathing would be problematic under the current arrangements. Residents make good use of both the lounge and the dining room. There is a bureau in the dining room, which staff use to store some records and to work at during the day if necessary. It was recommended as a matter of good practice that the notices on the wall in this area were stored in a file, so as not to detract from the homeliness of the environment. The lounge is showing signs of wear and tear, and is due for redecoration. A small number of other items require attention, and these are detailed at the end of this report. The kitchen and laundry areas are on a domestic scale. Residents are able to access the kitchen and are encouraged to do so. There are no major adaptations to the house to cater for significant physical disability. Currently, equipment available in the house is limited to handrails on the stairs and grab rails and bath board in the bathroom. One resident uses a wheelchair when going out. There are concerns about one resident who is anxious about periods of unsteadiness, and this is being investigated. Any significant deterioration in residents’ mobility will mean that the suitability of the environment needs reassessing. The house is kept clean and tidy, and hygiene is maintained to a good standard. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 & 36 Staff have a good understanding of residents’ needs and the care team is appropriately qualified. The current reliance on bank and agency staff needs to be reduced by recruiting to vacant posts. There is a continuous training programme in place for staff, and this should be developed further in accordance with residents’ assessed needs. Staff are generally well supported, but formal supervision in accordance with required standards needs to be better established. EVIDENCE: It was noted that both staff and residents appear comfortable in each other’s company and enjoy a good general rapport. Information provided in response to the pre-inspection questionnaire confirms that 60 of the staff team are qualified to NVQ 2 or above, thereby exceeding the required standard. Members of staff demonstrate that they have a good personal knowledge of the individuals in their care. There are 2 support worker posts and one senior care post currently vacant. Bank or agency staff are employed to cover these, and attempts are made to restrict the number of unfamiliar people working in the house by using the Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 21 same core group where possible, in the interests of promoting continuity of care. Recruitment to these vacant posts must be dealt with as a matter of priority. The schedule for staff training was seen, and this will be assessed more fully at the next inspection. In view of the assessed needs of the residents, it is recommended that additional training in supporting people with autistic spectrum disorders and impaired communication should form part of the core programme for this house. In addition, further training in the use of personcentred approaches should be made available to more of the care team, in order to ensure development in this area. Formal staff supervision is still not up to the required standard (minimum of 6 times in a twelve month period) but there is clear evidence that the manager is seeking to rectify this situation. The small size of the Home means that supervision can be direct, but dedicated time and proper recording of meetings should be the target, as a matter of good practice and in keeping with the relevant standard. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 & 42 The manager is sufficiently experienced and currently undergoing additional training towards qualifications appropriate to her post. The staff team and manager work well together for the benefit of the people in their care. The organisation is making positive efforts to ensure that residents’ views underpin service development appropriately. Work practices in the Home promote and protect residents’ welfare, health and safety. EVIDENCE: The current manager has worked as part of the staff team for several years and has recently been appointed to this post, having “acted up” since before the last inspection in October 2004. She is due to complete her NVQ level 4 qualification shortly, and intends to study for the Registered Manager’s Award immediately afterwards. Staff appear comfortable with the manager and the Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 23 team were open and entered into constructive debate throughout the inspection. There is evidence that the organisation has developed systems for quality assurance and monitoring of “customer satisfaction”, as referred to earlier in this report, and this is to be commended. The Service Manager also visits and reports monthly, as required by regulation 26. A recommendation that the new annual review report (being implemented by the company this year) should be sent to CSCI as a matter of course was made. The Service Manager, who attended for part of the inspection, undertook to follow this up. The fire safety records were examined and all tests, checks, servicing of equipment, drills and training had been completed or scheduled as appropriate. The COSHH cupboard was checked and found to be secure. An application to vary the conditions of registration should be made to reflect the ages of the current residents. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 24 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 2 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 1 1 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 2 2 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 2 x 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Yateley Avenue, 50 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 17 (2) Timescale for action Update the Statement of Purpose 31.07.05 to include complete information regarding shared bedroom. Outstanding since 30.12.04 Review individual contracts in 31.07.05 line with specifications of this standard. Review care plans and set 31.08.05 targets with measurable outcomes. Ensure that records of reviews show who takes part and how decisions are made. Review risk assessments and 31.08.05 cross reference to relevant care plan(s) Review and improve the range of 31.07.05 opportunities for residents to participate in the local community. Outstanding since 30.11.04 Ensure that Accident Book Within 1 recording complies with current day data protection legislation, and that incidents are reported to CSCI as appropriate Assess the options for improving 31.07.05 the natural light in the shared bedroom and advise CSCI of the outcome, including proposals and action plan. Redecorate the lounge, secure 31.08.05 Version 1.30 Page 26 Requirement 2. 3. 5 6 5 (b-c) 15 (1) 4. 5. 9 13 13 (4) 16 (2m-n) 6. 19 13 (4) 37 7. 25 23 (2f) 8. 28 23 (2) Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc 9. 10. 33 36 18 (1) 18 (2) 11. 39 24 (1-3) 12. 41 23 door handle and fit a door-stop to prevent damage to wall. Repair damaged wallpaper above hall radiator. Recruit to vacant posts as a matter of priority. Ensure that each member of staff receives formal supervision, keeping written records, at least 6 times in any 12 month period. Implement the Organisation’s quality assurance systems and make the information available to interested parties. Make an application to CSCI to vary the conditions of registration in accordance with the residents’ current ages. 31.08.05 31.07.05 31.08.05 31.07.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 19 28 35 Good Practice Recommendations Consult with Community Nurse (LD) concerning development of Health Action Plans. Remove notices from the wall by the bureau in the dining room. Further develop training opportunities for staff in personcentred approaches, autism and augmented communication. Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Yateley Avenue, 50 E54 S16930 Yateley Avenue V223487 240505 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!