Inspection on 07/03/07 for 50 Yateley Avenue

This inspection was carried out on 7th March 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

50 Yateley Avenue 14/03/08

50 Yateley Avenue 02/12/05

50 Yateley Avenue 24/05/05

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 Great Barr Birmingham West Midlands B42 1JN Lead Inspector Gerard Hammond Key Unannounced Inspection 7th March 2007 12:15 Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 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.V328914.R01.S.doc Version 5.2 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.V328914.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Yateley Avenue, 50 Address Great Barr Birmingham West Midlands B42 1JN 0121 358 0462 F/P 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) http/www.milburycare.com/home.html Milbury Care Services Limited Mrs Roseben Okeudo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the home can continue to accommodate two service users over the age of 65 years. Residents’ needs are kept under review. Date of last inspection 2nd December 2005 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.V328914.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows the key inspection completed during February and March 2007. Information was collated from a range of sources prior to the inspection visit on 07 March 2007, including reports submitted by the Manager and also by the Registered Provider. Direct observations and sample checking of records (including personal files, care plans, safety records and previous inspection reports) were also used for the purposes of compiling this report. The Inspector was able to meet with all three residents. Unfortunately it was not possible to seek their views directly, due to their learning disabilities and communication support needs. The Manager and three members of staff were formally interviewed, and a tour of the building was also completed. Following the visit to the house, the Inspector was also able to speak with relatives of two of the service users by telephone. What the service does well: What has improved since the last inspection? Clear efforts have been made to meet some of the requirements made at the time of the last inspection. Care plans have been developed and key workers are monitoring these each month. Improvements have been made to the home environment including a complete refit of the kitchen. Bedrooms have been redecorated and new furniture fitted. Action has been taken to improve the training and qualifications of the staff team, and the Manager is now formally registered. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 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.V328914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate information is available to guide any prospective resident in making a choice about the service, but needs to include information about current fees. Residents’ care needs are properly assessed so that support plans are appropriately informed. EVIDENCE: This group of residents has lived together for a number of years, and there have been no admissions since the time of the last inspection. A Statement of Purpose and Service User Guide are in place, but these have little relevance to the people living in the house, due to their levels of learning disability. Efforts have been made to present these documents in a more accessible format, but information on current fees is not available. Sample checking of residents’ personal records showed that their individual needs assessments have been updated. A detailed assessment (ELSI – Everyday Living Skills Inventory) has been completed since the last inspection visit. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6. 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have detailed plans about how they should be supported, but these could be improved by including clear information about how they communicate, and by being more person-centred. Work also needs to be done to set goals better, so that it is possible to see clearly whether or not they have been achieved. People are encouraged to make choices and decisions, but these are limited by individuals’ levels of learning disability. EVIDENCE: Sample checking of residents’ records showed that detailed care plans are in place. It was noted that one person’s care plan index was blank. This should be completed so that information can be located quickly and easily. Documents on file show that key workers review plans each month, but entries typically just show “no change”. This is fine as far as it goes, but whole care plans should be formally reviewed at six monthly intervals. As previously reported, Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 10 residents’ goals are in need of development, so that the outcomes can be clearly measured. The outcomes should be evaluated when the whole plan is reviewed, and goals amended or reset as appropriate. All three residents have high level communication support needs. Direct observations suggest that members of the staff team have a generally good understanding of how individuals communicate and what their different gestures, expressions, and so on, mean. It was noted that one person’s file had information about common Makaton signs, but it was not clear whether or not he could actually use and understand these, or if any work was going on to help him develop his communication skills. Another person’s file contained good information about how he communicates, but this needs to be brought together in one place. Care plans should include clear communication guidelines, and staff should work together to “pool” their knowledge and ensure that this is recorded appropriately. It is important to recognise that should existing staff leave (e.g. move to other jobs) that the knowledge they have acquired over a significant period of time could be lost if this has not been written down. Care plans are supported by detailed risk assessments and there are links to individual care plans. However, these should be reviewed, as it was noted that some assessments were old and some duplicated. Also, one person’s risk assessment index did not correlate with the actual assessments on file. It is further recommended that plans should be developed to make them more person-centred. It may be that staff need additional training or support in order to make best use of the range of tools available to achieve this. Staff were directly observed supporting residents to take part in things around the house according to their individual capabilities. One person was being supported to prepare lunch in the kitchen. Residents were also offered choices about what they would like and what they wanted to do. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to take part in activities of their choosing, but opportunities are sometimes limited. Making clearer links between what people do and their agreed goals could improve this. Service users are well supported to keep in touch with their families and loved ones. Residents enjoy their food and have a balanced diet. EVIDENCE: One of the residents has a day activity programme each weekday, split between a local college and day centre. The other two gentlemen are both of retiring age and their programmes are generally home based, though they also attend a local centre on a sessional basis. Records show that residents are supported to access local community facilities including local shops, cafes, restaurants and pubs. However, examination of personal files shows that Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 12 activity opportunities are still limited. It should be acknowledged that the ages of two of the residents is a limiting factor on the type and range of activities that are available, and staff reported that they did offer choices to go out, but these were often declined, particularly during the colder months. They advised that service users actively enjoyed listening to music, watching television (especially westerns, “action movies” and football) and DVDs. One of the residents made a particular point of showing the Inspector his collection of films, which he kept in his room. It is important that there are clear links between the activity opportunities that people can access and their agreed care plans and goals. This is an area that previous inspection reports have highlighted, and further work needs to be done to develop this. However, it should also be acknowledged that one resident has recently been diagnosed with a serious medical condition, and this will be a significant factor in future activity planning. The Inspector was able to speak with two of the residents’ relatives on the telephone following the visit to the home. Both said that they were able to visit when they wished and said that staff kept them informed about any important issues. As indicated above, staff were directly observed involving residents in preparing lunch. Choices were offered and pictorial aides are available to support residents make choices about what they want. Food stocks were examined and were plentiful and included fresh fruit and vegetables. Records of meals provided further evidence that residents have a varied and nutritious diet. During the inspection visit it was possible to directly observe residents enjoying their lunch. Staff had their lunch with them in the dining room and supported them appropriately, providing choices and assistance as required. The meal was unhurried and enjoyed in a relaxed atmosphere. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good basic personal care and are well supported to ensure that their healthcare needs are properly met also. Procedure and practice relating to handling medicine is generally satisfactory, but the system for checking stocks could be improved. EVIDENCE: The core staff group in this home has been together for several years now, and it is clear that they have a good understanding of the people in their care. Direct observation of interactions between residents and staff indicated that both were comfortable in each other’s company and enjoy a good general rapport. Service users’ grooming and dress provided further evidence that they receive a good standard of personal care. Relatives said, “I am very satisfied with the care (N) receives” and “Staff look after him well and care about him very much, he loves being there, excellent”. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 14 As reported above, one of the residents has recently been diagnosed with a serious medical condition. Staff are dealing with this professionally and with great sensitivity. Service users’ personal records provide evidence of involvement of medical professionals and other members of the multidisciplinary team, including GP, Consultants, Dentist, Optician, Continence Advisor, and Speech and Language Therapist. Residents have been supported to access full medical checks (“Health MOT”) at the GP and monitoring of individuals’ weights is being done on a monthly basis and recorded. Files contain a consent to care / treatment protocol. Records also include a detailed baseline assessment for individual Health Action Plans. These are now in need of review and plans should be developed further. None of the service users is able to administer his own medication. The Medication Administration Record was examined and had been completed appropriately. Records included service users’ photographs, copy prescriptions and written protocols for PRN (“as required”) medication. The Manager advised that she audits medication stocks at least monthly. It is recommended that the audit record be amended to show clearly “running totals”, including amounts of medication received, amounts held in stock and new balance. It should be possible to establish immediately from the record how many tablets should be held at any given date or time. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and procedure must be followed appropriately so that service users may be confident that their concerns are being listened to and taken seriously. Residents are generally protected from abuse, neglect and self-harm but all staff should be appropriately trained so as to minimise risk and raise levels of awareness. EVIDENCE: An appropriate complaints policy and procedure is in place. No complaints had been received in respect of this service since the last inspection. However, it was noted from an entry in a report made under the requirements of Regulation 26 (Care Homes Regulations 2001) that a complaint had been lodged with the Registered Provider. The Manager advised that one of the residents had made a complaint about the windows in his bedroom. This was not entered in the complaints log and it was not possible to find a record of any response from the Registered Provider. Due process has not therefore been followed, and it is required that this matter should now be followed up as a matter of some priority. There is also an appropriate Adult Protection Policy in place. In matters of complaint or protection, service users are generally dependent on the vigilance of members of staff to note changes in behaviour or demeanour as indicators Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 16 that some thing may be amiss. This reinforces further the need to have detailed communication guidelines as part of individual care plans. It was noted that three of the current staff team have yet to receive adult protection training, and this should also be rectified in the very near future. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26, 27, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in a house that is generally comfortable, clean and homely. Staff do their best to keep it that way but the Registered Provider should ensure that necessary repairs and maintenance are carried out as required. EVIDENCE: A tour of the premises was completed. Staff try hard to ensure that residents can enjoy living in a house that is comfortable clean and homely. Service users’ bedrooms are comfortably furnished and have all benefited from recent redecoration and or refurbishment. In particular it was noted that the upstairs back bedroom has been substantially improved since the last inspection by the installation of new furniture. New carpet has been fitted on the hall stairs and landing and in the lounge, which has also been redecorated. The kitchen has also been refitted. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 18 It was disappointing to note that some matters raised in the last inspection report have yet to be dealt with. These include repairs to the wallpaper over the hall radiator and to the bath panel in the upstairs bathroom. In addition, the hallway stairs and landing need redecorating, including the banister and woodwork. The window blind in the kitchen is dirty and should be replaced and the laundry room redecorated. The lounge furniture is in need of replacement, though the Manager advised that this had been ordered. In particular, it was noted that external woodwork, including the front door, is seriously in need of attention. The windows should be replaced, and the outstanding complaint referred to in the previous section relates to this problem, which has also been raised in previous inspection reports. In its current state this seriously detracts from the overall look of the property, which is now noticeably out of character with the other houses in the neighbourhood, which are generally well maintained. The back door is also damaged and in need of repair and the pointing around the kitchen window requires attention. The garden shed should also be made secure. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being supported by staff that know them well and are committed to caring for them. They are protected by the organisation’s practice in selecting and recruiting staff. Residents would benefit from improvements to staff training and qualifications, though they enjoy being cared for by a well-supervised and supported team. EVIDENCE: As reported above the core staff group is well established and has worked together for a number of years. Conversations with staff showed that they know the people in their care very well and are very committed to supporting them as best they can. Staff were directly observed giving support with understanding and patience. Recent medical problems have been recognised and staff expressed their determination to do what they can to ensure that residents continue to receive a good standard of care. The staff complement should be reviewed to ensure that sufficient numbers of staff are available to meet residents’ assessed needs. This should take into account recent developments and also the need to expand individual activity opportunities. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 20 Staff files were sample checked and all required documentation (including completed application, two written references, Criminal Records Bureau checks, and evidence of appropriate induction) was in place. Previous records show that 50 of the staff team hold qualifications at NVQ level 2 or above, and the Manager advised that all staff that are not qualified are now registered for NVQ training. The organisation offers a rolling programme of training for all staff. A copy of the staff training plan was seen, together with the request submitted to the Training Officer. The Registered Manager must ensure that all outstanding training is delivered and staff must also take responsibility for ensuring that opportunities provided are taken up appropriately. Sample checking of staff files provided evidence that formal supervision is up to the required standard, and a schedule of arranged sessions displayed on the office wall supported this further. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is generally well run. Efforts made to monitor and evaluate the quality of the service provided could be improved by making it clear how judgements have been made. Residents’ health safety and welfare are generally well protected and promoted. EVIDENCE: The Manager has been formally registered since the time of the last inspection. She is qualified to NVQ level 4 and has been working towards the Registered Manager’s Award. She advised that this is now completed and awaiting verification. Staff report that she is open and approachable. In particular one member of staff said that she was very supportive. It was further stated that Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 22 the staff group in general are very friendly, and that they all support one another. A requirement was made at the time of the last inspection that a report be produced of quality assurance and monitoring activity. This has now been done, and the report was on display in the home. This should be developed so that it is possible to see how judgements about service users’ views have been made, in view of their communication support needs. Safety records were sample checked. Weekly tests of the fire alarm and emergency lighting system have been done and a complete record maintained. The system has also been serviced and fire evacuation drills completed. Fridge and freezer, and water outlet temperatures have been tested as required. Portable appliance testing of electrical equipment has been carried out and the Landlord’s Gas Safety Certificate and 5 year Electric Hard Wiring Certificate are in date. Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X 3 X Yateley Avenue, 50 DS0000016930.V328914.R01.S.doc Version 5.2 Page 24 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. (Partially met) Review risk assessments and ensure that indices and assessments are up to date and not duplicated. Review and improve the range of opportunities for residents to participate in the local community. (Partially met) Ensure that the complaints procedure is followed appropriately and follow up outstanding complaint from service user. Advise CSCI of the outcome. Ensure that all staff have received training in the Protection of Vulnerable Adults from Abuse. Repair bath panel in the upstairs bathroom Complete outstanding repairs, redecoration and refurbishment to shared and external areas of the home as detailed in the main DS0000016930.V328914.R01.S.doc Timescale for action 31/05/07 2. YA9 13 (4) 31/05/07 3. YA13 YA14 YA22 16 (2m-n) 31/05/07 4. 22 31/05/07 5. YA23 18 (1c) 31/05/07 6. 7. YA27 YA28 23 (2) 23 (2) 31/05/07 31/05/07 Yateley Avenue, 50 Version 5.2 Page 25 8. YA33 18 (1a) 9. 10. YA35 YA39 18 (1c) 24 (1-3) body of this report. Forward up to date schedule of maintenance and repairs for the home to CSCI Review staffing complement to ensure that there are sufficient numbers available to meet service users’ assessed needs, including undertaking appropriate activities in the home and out in the community. Ensure that all outstanding staff training is delivered. Develop the system for reporting on quality assurance and monitoring activity in the home to show clearly how judgements about service users’ views have been made. 31/05/07 30/06/07 31/05/07 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 YA1 YA19 YA20 YA35 Good Practice Recommendations Include information about current fees in the home’s Statement of Purpose / Service User Guide Consult with Community Nurse (LD) concerning development of Health Action Plans. Develop system for auditing medication stocks to show clearly medication held, new stock acquired and revised stock balance. Further develop training opportunities for staff in personcentred approaches, autism and augmented communication. 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