Care Home: 64-70 Holbrook Avenue

Similar services:

• 10 Whitfield Avenue
• 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

What the care home does well The home is well furnished and homely which means that people have a comfortable place to live. Bedrooms were decorated and furnished to a good standard; they contained personal possessions, photographs and other effects. Consideration has been given for one person who does not wish to have many personal effects in their room. A lunchtime meal was observed and staff were seen to sit with residents and give help where needed in such a way that maintained the resident`s dignity and safety. People are supported to gain access to advice from health professionals where they need it so their health needs can be met. The service provides daily in-house activities. This provides people who live there the opportunity to participate in their interests and preferences both within and outside of the service. The home has a complaints policy in place. Staff were aware of how people with limited verbal communication make their needs known. At the time of this inspection we had received no complaints. The home has a good system in place with regard to the appointment of staff. Records seen show that references are always obtained, and staff are not appointed prior to safety checks being undertaken. The number of staff on duty enables the needs of the people living there to be met. What has improved since the last inspection? Work has been undertaken to redecorate areas of the home. Further work is planned to continue with the home`s redecoration. Staff training is being provided to ensure all staff are receiving required mandatory training. Those who have yet to complete all mandatory training, plans have been made to ensure this is achieved. Care plans and risk assessment have been reviewed to provide up to date information on the needs of the people who live there. What the care home could do better: The service needs to ensure policies and procedures are in place in relation to Vulnerable Adults. This will ensure that staff take the appropriate action if there are any allegations or suspicion of abuse, and will equip staff to meet the needs of people living in the home whilst carrying out their work safely. The service manager and team leader need to ensure that regular audits are carried out to ensure all medication is accounted for and correctly stored. CARE HOME ADULTS 18-65 Holbrook Avenue, 64-70 Holbrook Rugby Warwickshire CV21 2QQ Lead Inspector Julie McGarry Unannounced Inspection 6th August 2008 08:00 Holbrook Avenue, 64-70 DS0000068552.V369523.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 Holbrook Avenue, 64-70 DS0000068552.V369523.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. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Holbrook Avenue, 64-70 Address Holbrook Rugby Warwickshire CV21 2QQ 01788 577239 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) Coventry and Warwickshire Partnership Trust Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care and accommodation to 4 service users under 65 for reasons of learning disability. 17th August 2007 Date of last inspection Brief Description of the Service: 64-70 Holbrook Avenue is a purpose built bungalow close to the town centre of Rugby. It provides a service for up to four adults with learning disabilities. The home has recently reregistered under Coventry and Warwickshire Partnership Trust and is staffed 24 hours a day. The property is leased from Leicester Housing Association. The home has a large garden, parking and level access. There are four single bedrooms each with toilet facilities en suite and doors onto a small patio area and the garden. The house also has a small lounge, dining room, kitchen and laundry. The office and staff sleeping-in accommodation is combined. Two parks and Rugby town centre are within walking distance. Information regarding funding was not available at this inspection. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2star. This means the people who use this service experience Good quality outcomes. This Key Inspection was unannounced; it was undertaken over one day on the 6th July 2008. This inspection was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home, the service manager and team leader were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection along with one survey completed by a person who lives there. Due to the communication needs of the person who lives at this home, the survey was completed with support from relatives. The people who live at this home have communication needs and rely on staff support to recognise and respond to their needs and wishes. The service manager was present throughout the inspection. The home currently has no manager in post and the team leader is managing the day to day matters with support from the service manager. The service manager informs that the service has appointed a new manager, who is due to start in September 2008. Policies, procedures and care records were examined. Staff records, environmental checks and risk assessments were also read. During the inspection, the care of two people who live in the home was examined in detail. This included, reading assessments, care plans, and other documentation, observing care offered to them and that staff have necessary skills to care for them. This is part of a process known as ‘case tracking’. Where evidence is matched to outcomes for the people who live in the home. Specific elements of one other person’s care were also looked at to see if the outcomes are good. The inspector ate lunch with one person who lives in the home in the lounge, and was able to observe practices, and how staff interacted with individuals through out the visit. The inspector would like to thank the service manager, staff and the people who live at Holbrook Avenue. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Work has been undertaken to redecorate areas of the home. Further work is planned to continue with the home’s redecoration. Staff training is being provided to ensure all staff are receiving required mandatory training. Those who have yet to complete all mandatory training, plans have been made to ensure this is achieved. Care plans and risk assessment have been reviewed to provide up to date information on the needs of the people who live there. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 7 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. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 8 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 Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 9 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 and 5. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to decide if the home can meet their needs. They have their needs assessed and a contract that tells them about the service they will receive. EVIDENCE: The home has a Service User Guide and Statement of Purpose in place. As identified at the last inspection, the Statement of Purpose would benefit from being updated. Information about the weekly fees and other charges should be included in the Service User Guide. Two files of people who live at the home were viewed and both contained contracts for their stay there. The contracts were available in easy read format. Detailed pre admission assessments were on file for both people. As no new people have moved to live at Holbrook Avenue since the last inspection, the pre assessment process was not examined as part of this inspection. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The outcomes for people who use this service are good and people are supported to make everyday choices so that they can exercise some control over their daily lives. Care plans and risk assessments are completed in detail to describe people’s individual needs to ensure that they receive the care and support that they require in a consistent manner. EVIDENCE: Care plans of two residents were examined. These were detailed in providing guidelines for staff in supporting residents and the home uses a person centred planning approach with aspects of the care plans. For example, one person displays ‘challenging behaviours’, information on how this managed appropriately is recorded in that persons file as well as risk assessment having been carried out to ensure other people who live there are safe. Staff also informed us at the start of the inspection, what to expect in relation to this Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 11 person’s behaviours. Information provided by staff reflected that detailed in the risk assessment plans. Another care plan told us that one person receives support from the district nurse to help manage skin integrity. The care plan tells staff how to support this person and possible risk associated to skin breakdown. Due to one person’s mobility needs, bed rails and bumper are required for support. There is no risk assessment plan in place in relation to the need for bed rails and bumpers. Comments by staff and the service manager demonstrated detailed knowledge of people’s care needs reflecting information contained within the care plans. Observation of staff practices showed that staff are aware of peoples individual needs and how care needs to be provided to ensure that the privacy and dignity of people who live there. One commented from a survey completed by a member of staff said ‘The service in which I work is very person centred, it does look at each individuals needs and responds accordingly’. Each person living at the home has at least one key worker. Each person is encouraged to take part in the planning of their care through key worker meetings. However, due to people’s individual needs, this can not always happen in a formal way. Staff use alternative ways to understand the views and wishes of the people who live there, for example, through monthly house meetings and maintaining daily records detailing responses of people to the way care is provided and activities offered. From discussions with staff and looking at individual care plans, it was evident that people are encouraged to maintain and develop their independence. On the day of the inspection all three people at the home were supported to go shopping to buy personal items and food for the home. Staff hold meetings with the people who live there every Monday and Friday to make decisions about menu choices and activities preferences. Care plans and daily records also detail information on promoting peoples independent living skills through such activities tidying bedroom and hovering, house shopping and cooking – making jelly. Due to the physical and learning needs of the people who live there, they require staff support to make any meals / snacks. It was seen that staff understood when residents were indicating that they wanted something and staff responded in a timely and respectful way. Staff were observed offering choices to the people who live there. The people who live here have communication difficulties. Staff were observed communicating with the people who use the service effectively and respectfully. Care plans detail information to guide staff how to communicate with each person in their preferred styles. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 12 Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their life style, and supported to develop life skills. Social, educational, and recreational activities meet individuals’ expectations. EVIDENCE: Activity planners are in individual care plans and show that people do different things each day either in small groups or on a 1:1 basis with staff. From looking at the information in the care plans of the two people “case tracked” it was evident that the activity planners reflected individual preferences. For example, one person enjoys gardening. The activity plan includes time for that person to go into the garden to their personal patio area to water the plants. Another person likes to go horse riding, again the activity planner shows that arrangements are made for this person to go horse riding. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 14 Daily records were looked at which showed that people had access to a range of activities such as going out to places of interest, including the shopping, going out to the pub, and to such places as Coombe Abbey and Daventry Country Park. Mealtimes are relaxed and unhurried. A lunchtime meal was observed and staff were seen to sit with one residents and give assistance where needed in such a way that maintained the resident’s dignity and safety. The lunchtime meals were very well presented and appeared appetizing. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including smoked mackerel, vegetable risotto and home made chicken and mushroom pie. Some of the people maintain links with their family. There was evidence in daily records that people’s needs with regard to keeping in touch with friends and relatives had been recorded. Staff informed that not all people who live there have regular contact with their families , however staff try and encourage this by keeping families informed by inviting the to multidisciplinary meetings and sending them copies of the minutes of the meetings. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Records that describe individual’s health and medication needs are completed in detail to describe how those needs should be met, and staff have a good understanding of how to offer care and support to each person. The service manager and team leader need to ensure that regular audits are carried out to ensure all medication is accounted for. EVIDENCE: Staff were observed in supporting residents in a sensitive, calm, and warm manner that enhanced their personal dignity. Interactions between staff and service users were easy-going and good-natured, with requests for help being heeded in a timely manner. Residents were all smart in their appearance, their clothes were clean and fresh and appropriate to their individual lifestyle and needs. Health records looked at evidence that people have ready access to a GP and other health professionals locally including, consultants, dentists, speech and language therapists, opticians and chiropodists. And discussions with staff and Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 16 management, showed a full involvement with community and specialist health services. On the day of the inspection, one professional spoken to commented that she had ‘no concerns’ about the quality of care provided at Holbrook Avenue and ‘staff are friendly and helpful’. A suitable lockable cabinet is in place for the safe storage of medication at the home. The cabinet was well ordered and not overstocked. The temperature of the cabinet is not maintained to ensure medications are stored below the required 25 degrees. The pharmacist delivers medication in blister packs. The medication sheets show that the number of tablets received into the home so that they can be accounted for and that staff are signing for the medication given out. Good practice in the administration of medication after lunchtime was observed. Staff were seen to be patient with people taking their tablets, and staff talked to individuals about what tablets they were being given. Staff signed the medication administration records (MAR) after the medication was given and the person had taken it. The sample recordings looked at were all seen to be accurate. However we noted that there was only one tablet in the blister pack for the next day’s medication when there should have been two. As the pack has not been opened, it would appear that this was an error at the pharmacy and not the home. The home should however have ensured the correct amount of medication was delivered by the pharmacist and informed the pharmacy of the omission. The service manager and team leader need to ensure that regular audits are carried out to ensure all medication is accounted for. Two tablets from one person’s medication are kept in small case for when they go out. The medication in the case was not clearly labelled to indicate what the tablets were. This could lead to some confusion if the tablets are required when out in the community. There are no records on file to show that two tablets are kept separate from other tablets for that person. It was observed that two different brands of one type of medication are kept in the same box. Staff need to ensure that all medication is kept in the original boxes. This will ensure that details about the medication and who it is prescribed for are clearly shown. The home currently carries no controlled drugs that would necessitate any special storage and recording arrangements. There are no drugs that need to be stored in the fridge. There are a range of policies and procedures in place relating to administration, covert practices, training and disposal of medication in each individual’s medication folder. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 17 Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen and respond to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: Staff were seen to be attentive to service users’ needs, using knowledge gained from experience, where communication was not clear. We observed staff taking time to listen and observe peoples signs to ensure they understood peoples views. There is an accessible complaints procedure ‘Letting us know’ in place at the home with pictures to help people to understand the contents. The complaints procedure is contained in people’s files and Service User Guide. The complaints records seen during this visit showed that there has been one complaint made about the home since the last inspection. The complaint made relates to a staff member smoking when out in the community with a person who lives at the home. The complaint was made by an anonymous person. The information from the anonymous person did not state which member of staff the complaint was about. As the service could not identify who the complaint was about, the service manager addressed this complaint in the team meeting that was held on the day of the inspection. Staff were reminded of the disciplinary procedures in place in relation to this and similar matters. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 19 Staff were seen to be attentive to service users’ needs, using knowledge gained from experience, where communication was not clear. Staff development records showed that the majority of staff had completed National Vocational Qualifications (NVQ) which includes sessions in safeguarding vulnerable adults. The home does not have a safeguarding policy in place. The service manager assured us that this would be done. Two staff on duty discussed their understanding of the procedures in relation to safeguarding and both were clear about what do should a safeguarding matter arise. A training certificate was seen in one staff file as verification of this. The people who live there would benefit from all staff being trained and informed of complaints procedures and safeguarding procedures. There have been no safeguarding concerns at the home since the last inspection. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, safe and comfortable environment that meets their individual needs. EVIDENCE: Holbrook Avenue is a purpose built bungalow close to the town centre of Rugby. It provides a service for up to four adults with learning disabilities The home has a mini bus, to transport people to various activities. The home has a large garden, parking and level access. There are four single bedrooms each with toilet facilities en suite and doors onto a small patio area and the garden. The house also has a small lounge, dining room, kitchen and laundry. The office and staff sleeping-in accommodation is combined. People living in the home appeared comfortable sitting in the lounge, their rooms or ‘pottering about’ and using all the spaces in the home. One person was seen to freely walk out into the spacious gardens. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 21 The bedrooms are modern and personalised. Due to one persons mobility needs special equipment is required. Their room size is sufficient to safely manoeuvre the equipment required. One person has sensory equipment in their room to meet their individual needs and preferences. Another persons room appears sparse of personal possessions, however due to the needs of this individual, it is evident staff have responded appropriately and included the furniture and possessions that person wishes to have in their room. There is an ongoing redecoration programme in place. The service manager tells us that the lounge area and hallways are due to be redecorated. During the tour around the home, it was evident that some plaster work is needed to cover up some slight damage to one wall. The building was clean and there were no unpleasant odours, which indicates that effective cleaning and infection control procedures are in place. Staff were observed to be wearing aprons and gloves when carrying out personal care and domestic tasks. During the visit a light in the hallway started to flicker, arrangements were made that day for the light to fixed. As personal care is provided to people in their rooms, staff need to ensure that paper towels are available in each bedroom for staff use. At night time, there is one sleeping staff member and one waking staff member. There is no ‘sleep–in’ room, so staff sleep in the office. The kitchen was clean and well organised. Records were kept of the fridge and freezer temperatures showing appropriate temperatures to maintain good food safety. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 22 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, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: It was evident from watching staff at work that they have formed meaningful relationships with the people who live at Holbrook Avenue. Three staff files were looked at to ascertain whether recruitment policies were robust. The recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 23 Records show that staff are not receiving regular formal supervision. This was confirmed by staff spoken to. The total number of staff within the home is nineteen; this excludes the post of a full time manager who is due to take up their post in September. The managers hours will be supernumerary. Until the manager takes up their post, the service manager states that she is providing regular support through visits to the service. Information supplied by the team leader state that 14 members of care staff are qualified to National Vocational Qualification in Care Level 2 (NVQ level 2). This is above the national Minimum Standard for 50 of staff to be qualified. This should mean that residents benefit from having their needs met by staff that are appropriately experienced and qualified. The training records of staff working at the home were seen and demonstrate that staff receive mandatory training or training for staff to receive this has been planned. Staff present during this visit were able to answer our questions about meeting the needs of people who live in the home and have clearly got to know them well. Staff interacted with people, in a positive, relaxed and calm manner, being attentive to needs, no matter how expressed, and responding in ways that upheld their dignity and well-being. The home does not have any domestic or catering staff. Care staff take on these duties during their shifts. Most of the care staff are trained in food hygiene. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 24 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, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in a way that listens to and acts upon the views of the people who live there. The management of some areas of health and safety practice needs to be improved to ensure people are protected from potential risk of harm. EVIDENCE: At the time of this inspection there was no manager in post. The service manager told us that the post has been offered, and the candidate has accepted to take up the position in September. Until the position is filled, there is a team leader on duty and she is supported by the service manager. People who work at the home felt that there was a cohesive staff team and the absence of a manager has not had any negative impact upon the people who Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 25 live there. One staff member felt ‘the team has pulled together in the absence of a manager’. The Annual Quality Assurance Assessment (AQQA) completed by the service manager was completed to an adequate standard. Information provided was supported by a range of evidence, and the Annual Quality Assurance Assessment (AQAA) informed us about changes the home has made and where improvements still need to be made. The service manager visits Holbrook Avenue on a regular basis to report on the standard of care provided of which reports are made available within the home. From the most recent reports, minutes of meetings and discussion with the staff team, it was evident that the views of people who live in the home had been actively sought with regard to the way in which the service is being run. We were told that there are regular house meetings so that people have an opportunity to discuss issues that are important to them, such as planning activities and menus. The service manager informs us that the people who live at Holbrook Avenue are also invited to attend staff meetings. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. Staff spoken knew where the fire assembly point was, however told us that they had not taken part in a fire drill in recent months. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 26 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 Requirement All medicines must be stored in accordance with the legislation (The Royal Pharmaceutical Society). This is to ensure that the safety of medication and those who use the service. Staff drug audits need to be undertaken to ensure all medications are accounted for. Appropriate action must be taken when discrepancies are found. Timescale for action 31/08/08 2. YA20 13 31/08/08 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 YA23 YA35 Good Practice Recommendations The service manager needs to ensure Polices and procedures are in place for the safeguarding of the people who live there. Staff to continue to receive mandatory training opportunities. Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Holbrook Avenue, 64-70 DS0000068552.V369523.R01.S.doc Version 5.2 Page 29 - 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!