Inspection on 25/07/06 for 1 Michigan Way

This inspection was carried out on 25th July 2006.

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 25/11/05

1 Michigan Way 11/07/05

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 SO40 8XE Lead Inspector Debbie Oliver Unannounced Inspection 25th July 2006 10:00 X10015.doc Version 1.40 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 1 Michigan Way DS0000011984.V301809.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 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 DS0000011984.V301809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Michigan Way Address Totton Southampton Hampshire SO40 8XE 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) 023 8086 5753 www.new-support.org.uk New Support Options Limited Mrs Nicola Stewart Care Home 5 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (5) of places 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category LD referred to above must be at least 40 years of age. 25th November 2005 Date of last inspection 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. On the 1st August 2006 the fees for the home were £1339.52 per week and this includes 7 hours day services per person. Information about the service provided at the home would be made available to potential service users by providing a copy of the home’s service users guide and statement of purpose. A copy of the last inspection report is available in the home. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over two days and six hours. During the visit, records and documents were examined, an opportunity was taken to tour the premises and staff working practice was observed. The inspector met all four service users, and managed to speak with two of them. Observation enabled the inspector to gain a better understanding of how the needs of service users were being met. There were no service users from ethnic minority groups. What the service does well: What has improved since the last inspection? What they could do better: Each individual plan needs to be reviewed to ensure all the information is current, up to date and in use. Additionally the personal planning of activities needs to be kept up to date to indicate what new opportunities service users have experienced. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 6 Staff training files need to be up to date to show staff have received relevant training. There needs to be an audit trail in relation to accidents within the home. 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 DS0000011984.V301809.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 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 the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s systems and procedures ensure the needs of existing and prospective service users are identified. EVIDENCE: There have been no new admissions to the home. One service user recently died and so there are now four service users living in the home. The assessments were viewed during the last visit and were satisfactory. As the four service users living in the home have lived there for many years and there have been no new admissions the assessments were not viewed on this occasion. The four service users had evidence of regular reviews within their plans. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 9 On observation throughout the day it was evident staff can meet service users’ needs. None of the service users were assessed and referred solely for intermediate care. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 10 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 the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The personal, physical and health care needs of service users are well met and the procedure for the receiving and administering of medication is robust ensuring a safe system for service users. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Two service users were case tracked and there are daily plans detailing the individuals’ routine. The plans show how service users like to be supported in regard to their personal care including what they need help with and what they can do for themselves. Regular reviews were in place. The one service user who needed support whilst bathing has now had this information included in their plan. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 11 Staff spoken to confirmed service users have positive input from opticians, general practitioners, dentists and chiropodists and there was evidence in the plans to show this happens. Service users also said they see their Doctor as they need to. Risk assessments are in place with review dates It was however discussed with the manager that there is a lot of information in the plans that are either quite old or have not been completed. It was agreed there needs to be a review of the information and the manager said all information is currently being updated. The medication is kept in a locked cupboard and the home uses the NOMAD system. The procedure for the receipt, administration and disposal of medication is satisfactory. A running total of as required medication is also kept. All four service users in the home would tell staff if they were in pain and need pain relief. All staff have received training in administering medication and the two staff members spoken to confirmed this. The inspector also saw the certificates. No one in the home is prescribed any controlled medication. Service users spoken to said they felt well cared for and that staff treat them well. During the visit staff were seen knocking on bedroom and bathroom doors before entering and using service users’ preferred names. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 12 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 the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities to engage in suitable activities and are part of the local community, so promoting independence and choice. Contact with families is well supported, and nutritional needs of service users are well managed. EVIDENCE: Service users’ social and cultural needs are recorded in their care plans. Service users spoken to said they enjoyed the activities they take part in. On the first day of the visit two service users had gone out for the day and the other two service users were going out to lunch. Each service user has personal planning information about agreed activities but it was discussed with the manager when an activity has taken place this also needs to be documented so it shows how service users are being supported to undertake new opportunities. Staff are in the process of supporting service users to compile a picture board showing them on various trips. Contact with families is very positive. Most service users have regular contact with their families and this is documented in their plans. One service user 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 13 spoken to said they visit their brother once a month for the weekend. They also see their niece and nephew. Service users were seen accessing all parts of the home and staff were seen using appropriate language for service users and asking rather than demanding things of service users. One service user showed the inspector their bedroom and had their own key and the bedroom was locked. A menu was seen and offered a varied and nutritious diet with space for alternatives as needed. The menu takes in to account the likes and dislikes of service users. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 14 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 the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Arrangements for protecting service users and responding to concerns are satisfactory. EVIDENCE: The complaints procedure is available and this is in a pictorial format to aid understanding. One service user spoken to said they would talk to staff and tell them any problems they have. The complaints log was also seen and there have been no complaints. The home has the relevant procedures and policies and all staff have received training in adult protection. One member of staff spoken to demonstrated a good understanding of adult protection issues and the action to be taken in the event of an allegation of abuse. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A comfortable, safe and hygienic standard of accommodation is provided for the service users, which meet their needs. EVIDENCE: The inspector toured the home and it is well maintained and suited to the service users’ needs. It is decorated to a standard that creates a comfortable and homely ambience. The home is well furnished with good quality domestic fixtures and fittings. There is also a regular programme of maintenance by the housing association, who owns the building. The manager confirmed the hot water is tested every week as well as every time a service user has a bath or shower. The only area where the water is particularly hot is the kitchen and this is constantly monitored. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 16 The home was clean and hygienic throughout and infection control procedures were in place. Protective clothing is available to staff and these are kept in the laundry room. There is a separate laundry room with all the necessary equipment available. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 17 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has procedures and systems in place that ensure staff are properly recruited and that there is always enough staff on duty. The training in place shows staff have the necessary skills and knowledge to meet the complex needs of service users accommodated in the home. Regular supervision for staff ensures they are well supported. EVIDENCE: From observation and discussion with staff members, they have built good relationships with service users and have a good understanding of their behaviours. Three staff were spoken to and they indicated that they have received good training since starting in the home. The manager confirmed staff receive all the relevant training including mandatory training and is in the process of documenting all training received. It was also confirmed some training in Dementia has been held but the manager needs to access more in depth training for staff. The manager confirmed that for each new member of staff an induction book is completed and some were sampled. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 18 Staff spoken to confirmed they receive regular supervision and annual appraisals and that the manager is approachable and easy to talk to. There was adequate staff on duty at the time of the visit and this was confirmed on the rota. The inspector sampled two staff files and they contained all the necessary information relating to recruitment but the manager was advised to include the CRB disclosure number. Service users spoken to said ‘staff are nice’. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 19 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a well organised home and the quality assurance system ensures service users and their families are able to contribute their views for the development of the home. The system for maintaining the health, safety and welfare of service users is satisfactory, including service users’ financial interests. EVIDENCE: Staff spoken to said the manager is approachable and easy to talk to. They can go to her with ideas and she will listen. The manager said she has good line management support and the support of other peers. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 20 Senior managers of New Support Options visit the home every month to assess the service being provided. A copy of this report is then sent to the Commission. Families are fully involved and are asked their views on an informal basis. The manager confirmed if there were particular views from families these would be acted upon. Families are also invited to service user reviews. Staff discuss their views through supervision and team meetings, the minutes for these were seen by the inspector. House meetings for service users are also held but are quite infrequent. Views are usually gained on a one to one basis with a coffee whilst watching television. The manager confirmed two service users have complete control over their finances and for the other two the home keeps some of their money for safekeeping, the relevant documentation is in place. The home’s fire alarm system and extinguishers are checked regularly and records are made of these checks. Fire safety training has been provided to staff. The gas and electrics have also been tested and the inspector saw the certificates. Food was suitably stored and daily checks of the fridge and freezer were recorded. Accident books were also seen but as the incident is filed away there was no indication on who had the accident and the outcome. This was discussed with the manager. 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 21 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Michigan Way DS0000011984.V301809.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace 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 DS0000011984.V301809.R01.S.doc Version 5.2 Page 24 - 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!