Inspection on 11/07/05 for 1 Michigan Way

This inspection was carried out on 11th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1 Michigan Way 25/07/06

1 Michigan Way 25/11/05

1 Michigan Way 09/11/04

1 Michigan Way 14/04/04

1 Michigan Way 25/06/03

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 1 Michigan Way Totton Southampton Hampshire SO44 8XE Lead Inspector Craig Willis Unannounced 11.07.05 9:30 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 Older People. 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. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1 Michigan Way Address Totton Southampton SO44 8XE 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) 023 8086 5753 New Support Options Limited Mrs Nicola Stewart CRH 5 Category(ies) of LD(E) Learning Disability over 65 registration, with number LD Learning Disability of places 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Service Users in the category LD referred to above must be at least 40 years of age Date of last inspection 9.11.05 Brief Description of the Service: 1 Michigan Way is registered to provide care and accommodation for five people with learning disabilities over the age of 40. The home is situated in a residential area of Totton, within a quarter of a mile of a large shopping complex. The home has two lounge areas, one of which can be used by service users who smoke, a communal kitchen and dining area. Each service user has a single bedroom and use of a bathroom and shower room, both of which are accessible for service users with mobility difficulties. The service is provided by New Support Options, which has a number of similar services in the area. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and a half hours. The inspector spoke only briefly to three service users, due to their communication needs. Each service user had completed a CSCI comment card prior to the inspection with the help of the home staff. The inspector spoke to two members of staff who were on duty during the inspection. What the service does well: What has improved since the last inspection? New kitchen units and work surfaces have been fitted. This gives service users a more pleasant kitchen that is easier to keep hygienically clean. The home has obtained a current certificate of liability insurance. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 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. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 The home has a good assessment system, which assures service users their needs will be met. Service users are not admitted solely to receive intermediate care. EVIDENCE: The inspector viewed the records of all five service users. Each service user had a needs assessment, which included their mobility, communication, personal care, health needs and their daily routines. A section on likes and dislikes was included in the assessment. No service users have moved into the home since the last inspection and none of the service users were assessed and referred solely for intermediate care. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The home has care plans in place, although the system for completing and reviewing risk assessments is poor and may place service users at risk. Staff treat service users with respect and uphold their privacy. Access to health services and the medication systems in the home are good and protect service users. EVIDENCE: The records of all five service users were viewed and all contained a care plan setting out how the assessed needs of service users should be met. The plans had all been reviewed monthly and changes had been made where necessary. Some of the plans had several changes added and were becoming difficult to read. It is suggested that these plans could be re-written to make them clearer for staff to follow. Separate risk assessments had been completed for some service users, setting out action that should be taken to minimise the identified risks. No risk assessments were available for one service user and the risk assessment of one service user stated that the gate to the property must be kept shut. Staff spoken with said that this was not now necessary. Some of the risk assessments had been transferred onto a new form, although none of these had been reviewed since they were completed in July and October 2004. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 10 Records indicated that service users were supported to attend a wide range of health services, including GP, dentist, continence nurse, psychiatrist and optician. Details of the consultations were recorded, including any advice given by the practitioner. All of the service users stated on a CSCI comment card that they were able to see their doctor and dentist. Medication is suitably stored in a locked cupboard in the office and is obtained in a monitored dosage system. None of the service users are currently responsible for their own medication. Staff completed a weekly check of the medication held and the balance recorded matched the balance held. Medication administration records had been fully completed. One staff member spoken with confirmed she had undertaken assessed training before administering medication to service users. All of the service users completed a CSCI comment card stating that they liked living at the home, felt well cared for and that staff treated them well and listened to them. All bedroom, bathroom and toilet doors had locks and staff were observed knocking on doors before entering bedrooms. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 The home provides good food, giving a balanced diet for service users and support is provided for service users to exercise choice. EVIDENCE: All of the service users reported in the CSCI comment cards that they have meetings to talk about what is good and what needs to be changed in the home. Service users are able to bring their own possessions into the home and an inventory of possessions was available for each service user. The home had a planned menu that provided a balanced diet and took into account the likes and dislikes of service users. Three service users reported on the comment cards that they choose what they eat, and two said they sometimes choose what they eat. Staff reported that alternative meals were available and service users could take meals at different times if required. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has suitable complaints and adult protection procedures. Most service users know what to do if they have a complaint and are confident that staff will listen to them. EVIDENCE: The home had a copy of the New Support Options complaints procedure, which had been made available to service users in a pictorial format to aid understanding. In the CSCI comment cards four service users said they would talk to staff if they had a complaint, but one service user said they did not know what to do if they were unhappy. The manager should re-iterate the complaints procedure with all service users to ensure they are all aware of action to take if they are not happy. This will be followed up at the next inspection. No complaints had been received since the last inspection. All service users said in the comment cards that the staff listened to them. The home has adult protection procedures in place and one member of staff spoken with demonstrated a good understanding of adult protection issues and the action to be taken in the event of an allegation of abuse. One member of staff reported that they had not yet completed the adult protection training, but would report any allegations of abuse to the manager or the on-call manager. This member of staff reported that they were not working alone at present, until they had completed all of the induction and initial training. The staff rota indicated that this member of staff was not scheduled to work alone. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 and 26 The home is clean, safe and well maintained which provides service users with a pleasant, comfortable environment. EVIDENCE: The home is well maintained and is furnished and equipped to meet service users’ needs. The kitchen units and surfaces have been replaced since the last inspection and the dining room has been re-decorated. All of the hot taps are fitted with thermostatic mixer valves, one of which was tested each week. The temperature of water in the bath had not been tested for several weeks and was uncomfortable for the inspector to hold his hand under. Support was provided for all service users whilst bathing. The temperature of this water should be checked and the thermostat adjusted if necessary. This will be followed up at the next inspection. Radiators throughout the home are individually controlled and are covered to provide a low surface temperature. Emergency lighting was fitted throughout the home. The home was clean and hygienic throughout and infection control procedures were in place. Protective clothing is available for staff. There is a separate 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 14 laundry room that does not require soiled laundry to be taken through food preparation or storage areas. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The needs of service users are met through the numbers and skill mix of staff working. EVIDENCE: The home currently has one full time staff vacancy. The staff rota indicated that there were generally 2 staff on duty in the morning, 1 in the evening and 1 awake overnight. The staff member working the evening ‘sleeps in’ and is available on call if needed during the night. Additional staff were provided to cover activities, for example on the evening of the inspection service users were going on a boat trip, for which additional staff had been provided. Staff reported that they did not work alone until they had completed their induction training and probationary period. A requirement was made at the last inspection that the manager must complete records of inductions of new members of staff. It was not possible to check this as the manager was not present and staff did not have access to training records. One new member of staff spoken with confirmed that they had met regularly with the manager to work through her induction. Training and induction records will be assessed at the next inspection. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 38 The home has good systems to protect the health, safety and welfare of service users and staff, and has suitable accounting and financial procedures. EVIDENCE: The home has a current certificate of liability insurance displayed in the hallway, in compliance with a requirement made at the last inspection. New Support Options has a central finance team, to which the manager makes monthly returns of expenditure within the home. The accounts of the organisation were not inspected. The fire alarm was tested weekly and two evacuations have taken place in the last year. All staff have received fire safety training. The fire alarm and extinguishers are regularly serviced. The home has current gas and electrical safety certificates and portable electrical appliances are tested annually. Assessments had been completed for chemicals used in the home, which were stored in a locked cupboard. Information on health and safety issues, including details of legislation, were displayed in the office. 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 17 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x 3 x x x 3 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 19 No 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 7 Regulation 13 (4) Requirement The registered person must ensure that risk assessments are in place for all service users. Timescale for action 30/9/05 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. Refer to Standard Good Practice Recommendations 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 20 Commission for Social Care Inspection 4th Floor Overline House Blechynden Tearrace Southampton SO15 1GW 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 1 Michigan Way H54 S11984 1 Michigan Way V234397 11.07.05.doc Version 1.40 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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