Inspection on 16/07/08 for 8 Haslerig Close

This inspection was carried out on 16th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

8 Haslerig Close 16/07/09

8 Haslerig Close 13/08/07

8 Haslerig Close 27/06/06

8 Haslerig Close 27/01/06

8 Haslerig Close 25/11/04

8 Haslerig Close 17/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Haslerig Close (8) Harvey Road Aylesbury Bucks HP21 9PH Lead Inspector Barbara Mulligan Unannounced Inspection 16th July 2008 10:00 Haslerig Close (8) DS0000023040.V367471.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 Haslerig Close (8) DS0000023040.V367471.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. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haslerig Close (8) Address Harvey Road Aylesbury Bucks HP21 9PH 01296 331381 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) haslerigclose-londoneast@maca.org.uk www.together-uk.org Together Working for Wellbeing Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (0), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (0) Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th August 2007 Brief Description of the Service: Haslerig Close (8) is a detached house in a quiet cul-de-sac on the outskirts of Aylesbury with good access to local amenities and public transport. The home seems well integrated into the local community. The home provides twentyfour hour care for up to eight persons with a mental health problem. Accommodation is domestic in style and each service user has their own bedroom. The home is run by ‘Together Working for Wellbeing’ (formerly known as the Mental Aftercare Association (MACA)). There is an established staff team which is supported by relief staff. The staff team liaise with health professionals and other services in the community to ensure that residents receive appropriate care and support. The fees for this service are £800 per week. Haslerig Close (8) DS0000023040.V367471.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was conducted over the course of a day and covered the entire key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. Surveys forms were sent to people who use service and these were received before the site visit was completed. The inspection officer was Barbara Mulligan. The acting manager Mr Emmanuel Mensah and the senior carer Mr John Garside assisted with the inspection. This inspection consisted of discussion with the two staff on duty, opportunities to meet with some service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Twenty-six of the National Minimum Standards for Younger Adults were assessed during this visit. Twenty-four of these are fully met and three almost met. As a result of the inspection the home has received four requirements. Feedback on the inspection findings and areas needing improvement was given to the deputy manager at the end of the inspection. The two staff on duty and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Meals are of a good standard and presented in an appealing way. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. The home provides a comfortable environment in which people can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Communication between people who use the service and staff was observed to be positive and open. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 6 The home has a good, clear and a well advertised complaints procedure that provides residents with a clear process to follow if dissatisfied with any aspect of the service. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. Health and safety policies and procedures are clear and informative. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. What has improved since the last inspection? 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. Haslerig Close (8) DS0000023040.V367471.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 Haslerig Close (8) DS0000023040.V367471.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 and 2 Quality in this outcome area is good. The homes Statement of purpose and Service Users guide are good providing individuals details of the services that the home provides. Potential service users receive a thorough needs assessment undertaken by staff trained to do so ensuring that the home can meet the needs of all people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous inspection carried out on the 13th August 2007 the statement of purpose and service user’s guide were in the process of being updated. These documents were requested at this inspection. This has been combined into an information pack that is detailed and comprehensive. There are photographs included of the home, the garden and surrounding areas of interest. The information pack is available in Braille, large print or audio. Referrals are made via the local community mental health services funded by the primary care trust (PCT) and social services. At the point of referral the home has access to the person’s care plan (for mental health services this is known as the care programme approach (CPA)) and include risk assessments carried out by professional staff working with the community mental health team (CMHT). Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 9 This information is considered by the home and if the referral is to be considered further then the relevant multi-agency panel is informed. If the person is happy with the referral to continue then he or she completes an application form for a place in the home. The manager will then establish contact with the potential service user. This leads to an invitation to visit the home where an assessment, using the homes own assessment form, is carried out. If the referral progresses further then the person is invited to visit again, stay for a night and perhaps for a weekend before a four-week trial admission is arranged. At the end of the four weeks a review is held between the resident, home staff and the relevant member of the CMHT – care manager or community psychiatric nurse (CPN). Admission for as long as the person needs it is then agreed. There is no limit on how long a person may live in the home. There have not been any new admissions to the service since 2007. The records relating to the most recently admitted service user and two others chosen at random were examined and found to be in good order with a detailed and comprehensive needs assessment that indicated that the service user had been involved in the process. Haslerig Close (8) DS0000023040.V367471.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. Effective care plans are in place, which adequately document service users’ needs and how these are to be met, within a risk assessment framework. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of the three people living in the home was case tracked and their care plans were examined. These were variable in their content and layout. In one file looked at there were three care plans dated, 16/06/06, 15/01/08 and 15/04/08. Another files contained four care plans dated 09/04/06, 19/06/07, 20/08/07 and 22/01/08. There was also an action plan dated 11/05/04. Some files would benefit from a reduction of duplicated information to make them more user friendly and this is recommended. Each individual file contains the personal details of the person, the licence agreement with ‘Places for People’, a record of appointments with health professionals, risk assessment forms completed by the CMHT, assessment records, and correspondence. There is good evidence of multi-disciplinary working and each care plan shows evidence of regular review. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 11 Some care plans include a photograph of the person others do not. All care plans are signed by the service user and dated. Consideration needs to be given to how individual files and care plans can be formulated in a more person centred approach and are reflective of the personal preferences of each person. The inspector asked how people using the service are involved in the day-today running of the home. Staff said that regular meetings are held with people who use the service and the inspector observed the minutes of these meetings. These show that issues raised are managed appropriately and how staff support residents to make decisions. It is interesting to read that the subject of ‘Equality and Diversity’ is on several of the monthly agenda’s. An advocate from Aylesbury Vale Advocates visits the home regularly and was due to visit during the week to support residents to complete satisfaction questionnaires as part of the organisations quality assurance process. People who use the service were seen to make decisions during the inspection, such as what to make for lunch and what to buy at the shops. Risk assessments are recorded in care plans. These follow from the risk assessments carried out under the CPA and already recorded in care plans and correspondence. The process of risk assessment appeared an open one and involves the resident. Service users’ files provide lots of examples of people being supported to be as independent as possible, such as dealing with risks associated with the control of substances harmful to health (COSHH), dealing with finances, fire safety, using household equipment and a self medication assessment. All risk assessments were found to be up to date, signed and dated by the author. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area good. Residents have experience of a range of social activities and are involved with the local community. However the range of activities should be reviewed and increased, with potential benefits for the quality of life of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there were no residents living in the home who were ready for employment. Many residents keep in contact with friends or acquaintances and meet up with them at church, at a nearby mental health unit (the ‘Tindal Centre’) or at a social support centre (‘Wings’) in Aylesbury. On the day of the inspection visit all residents were at home. Staff explained this was because the day services were holding meetings/reviews and then Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 13 closing for the summer holidays. There does not appear to be any plans for recreational or other activities in place during this period. Residents make use of community facilities with adequate staff support to access these resources. These include trips to the shops, a fish and chip shop, café, and hairdressers. However, there is little evidence in care plans of further development and learning opportunities and there is little evidence of leisure and recreational activities taking place. This was identified at the previous inspection and needs to be addressed. There is a key worker system in place and staff told the inspector that regular trips are organised between the person using the service and their key worker. The home has recently gained a mini bus and staff said that they are organising day trips for the summer period. At the time of this inspection the home was able to meet the potentially diverse needs of its residents. Residents have variable contact with their families. There are restrictions about family and friends visiting and people who use the service are supported to maintain family relationships. In terms of equality the home has male and female residents and staff, a varying age range, residents with disability, residents with religious belief, and residents and staff of different ethnic origins. Meals are planned on a weekly basis. Food likes and dislikes are recorded in care plans. Advice from a dietician is obtained from Manor House Hospital when required. Meal times are flexible and the main meal is usually in the evening. The nutritional needs of service users are assessed and there is evidence of regular monitoring in care plans. Service users are weighed regularly and recorded in care plans. The home will offer drinks and snacks throughout the day in accordance with needs of each individual. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. The health and personal care needs of people living at the home are well met, promoting health and well-being. However, staff must complete accredited training in the safe handling of medicines, ensuring that service users receive the medicines they require, as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support is provided either in individual bedrooms or bathrooms. People who use the service are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. This information is recorded in care plans and includes discussions between the key worker and the resident when reviewing care and through consultation on a day-to-day basis. The homes routine is flexible and accommodates a range of needs. Staff are not always able to provide as much support to residents outside of the home because of staffing levels – although it was said that the duty rota can be adjusted for planned events. The residents were generally physically able and did not routinely require physical aids. However, one resident needs a Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 15 frame to provide support when walking. Such aids are acquired from local NHS services as needed. All residents were registered with a local GP practice. There is good evidence of health care screening in service users personal files. This includes dental and optical screening, incontinence clinic, breast screening, wheelchair fitting, smear test and orthopaedic clinic. Podiatry services are accessed via the local health centre. Medicines are prescribed by the resident’s GP, or, in the case of Clozapine, the psychiatrist. Medicines are dispensed in a monitored dosage system (MDS) form. Staff practice is governed by the organisation’s policy. The policy, which is categorised under health and safety policies, was last reviewed in 2002. There is a supplementary policy statement on medication records, which was issued in 2005, and this needs to be reviewed. Staff training consists of the Boots one-day course. Some dates for this training goes back to 1998. The home does not currently have arrangements in place for assessing competence after training or for periodic update training. The inspector was shown the organisations training schedule for the next twelve months. They have introduced two medication training courses. One is an introduction to medicines and the second is an advanced course. However no member of staff has attended an advanced course and this will be a requirement of the report. No residents were administering their own medicines at the time of this visit. At the previous visit. The acting manager at the time of the previous inspection said that this is to be addressed by the home in the near future. This had not been addressed at the time of this inspection. The inspector examined medication records and it is pleasing to note there were no omissions observed. Records show all medication received, administered and leaving the home, or disposed of. There were three residents using controlled drugs in use at the time of the visit. There was a book for each person that was signed by two staff on all occasions and a record kept of the stock of the medicines. At the previous inspection it was noted that the colour of some MDS containers did not correspond with the time the medicine was due. Staff in the home had to write this on the container. This should not be necessary. The dispensing pharmacy should dispense the drug in the correct colour container and it should not be necessary for staff to make amendments. Staff said that this has now been resolved and the supplying pharmacist has made significant improvements. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area good. Procedures for managing complaints and adult protection are in place that ensures that service users or their representatives are listened to and people who use the service users are protected from abuse and harm and their rights to be safe are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Copies of the complaints procedure are included in the Statement of Purpose and the Service Users Guide and this gives guidance about referring a complaint to the Commission for Social Care Inspection in Oxford. This needs to be changed to the new address for the Commission in Maidstone. The complaints procedure is clear and includes the timescales for responding to complaints. The complaints procedure is set out in text and picture, and there is a flow chart form on the notice board in the lounge area and a copy of the complaints procedure is included in each persons care plan. The homes complaints log shows that the home has not received any complaints since the last inspection. The Commission has not received any complaints about this service. There is a policy governing the protection of vulnerable adults (POVA) dated November 2005. There is also a copy of the Buckinghamshire joint agency policy accessible to all staff for guidance. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 17 Training records show that all care staff have received safeguarding/protecting adults from abuse training and this is provided locally by an independent training agency. There have been no safe guarding adult referrals. Arrangements are in place for assisting residents in managing money. These include secure facilities for cash and valuable in their rooms, secure facilities in the staff office for storing cash, arrangements for bank accounts for residents, recording of all transactions, and checking balances at each staff handover meeting which was seen to take place on the day of the visit. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 and 30. Quality in this outcome area is adequate. The building is comfortable, and clean providing a homely and accessible home for residents. However, prompt attention to repairs and maintenance of the home needs to be sustained, to ensure it remains safe and accessible to the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a detached house, situated in a residential area near to Stoke Mandeville Hospital, about one and half miles from the centre of Aylesbury. There is limited parking to the front of the home but sufficient alternative parking in nearby streets. The nearest rail stations are Aylesbury (about 1.5 miles away) or Stoke Mandeville (over 2.0 miles away). Residents also use the local ‘Dial-a-Ride’ bus. There are shops, a café, and hairdressers within walking distance. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 19 Following the previous inspection a requirement was issued for the property to be maintained in a homely, comfortable and safe environment. Repairs identified at the previous inspection have been completed. The accommodation is over two floors. The ground floor is reported to be accessible to a wheelchair user although no resident required a wheelchair within the home at the time of this inspection. There are eight bedrooms. All bedrooms are single. None have en-suite facilities. Two of the bedrooms are on the ground floor. Entry for visitors is controlled by staff. Residents have keys to the front door and to their bedrooms. The ground floor accommodation comprises the entrance hall, two bedrooms, shower room, WC, laundry, open plan living and dining area, kitchen, staff office, staff sleep-in suite, conservatory (now the only area where smoking is allowed), and garden. Some of the furniture in the conservatory is very badly stained, has cigarette burns in it and some seat cushions are without covers. Some of the furniture in this room needs to be replaced. The first floor accommodation comprises six bedrooms, two bathrooms, WC’s, and store cupboard. The carpets in the hallways and on the stairs of both floors are badly stained and need to be replaced. As described in the previous report the recently fitted kitchen remains a disappointment for residents and staff. A new kitchen was installed but the quality is not up to the standard required in this type of service. Drawers and cupboard doors are damaged, the laminate was separating in a number of areas, but particularly on work surfaces. This is not just unsightly and unsatisfactory but will in time pose a health hazard in an area where food is prepared. This was again the case on the day of this visit. The laundry is adequate for current use. There are two washing machines, one tumble dryer, ironing facilities and a sink. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area good. The staffing numbers and skill mix is adequate and improvements have been made in staff training to ensure that people who use the service benefit from staff who are who are competent to do their job. Recruitment procedures are undertaken to ensure staff have the right skills and competencies to support the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels on duty were adequate, with currently two care support workers in the morning, two care support workers in the afternoon and evening, and one waking care support worker and one sleep-in support worker at night. The manager is extra to these staffing numbers who usually works during office hours, Monday to Friday. A domestic assistant works on five mornings a week. The home does not employ volunteers. Staff turnover was described as low. The staff group is mixed in terms of age, gender and ethnicity. Staff meetings are held every two weeks and notes are taken and filed. Some Progress has been made with NVQ training. The AQAA informs us that three permanent care staff and one bank worker have achieved NVQ level 3 training or above. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 21 Following the previous inspection a requirement was issued for staff files to contain all of the information required under Schedule 2 Four staff files were viewed at this inspection, including those new to the service. The organisation’s human resources department in London supports the recruitment of new staff. All applicants are required to complete an application form and a health declaration. Health declaration forms are checked by an external occupational health service. One file looked at had only one reference contained in it and some files contained photographs and others didn’t. Two Criminal Records Bureau (CRB) checks were dated 2003 and it is recommended that where these are dated 2003 or 2004 that these are renewed. The remaining files all contained the necessary information as detailed in schedule 2 of the Care Homes Regulations. There is a corporate induction programme in place that will ensure new care workers are familiarised with the organisation and their roles and responsibilities This covers work familiarisation, roles and responsibilities, conditions of employment, access to policies and procedures, health and safety and training and development. However staff said that there is a long delay between commencing employment and undertaking the necessary mandatory training. This is discussed further under health and safety. Induction certificates were seen in staff personnel files. There is specialist training available for staff, an example of this is dealing with aggression and violence. Staff confirmed that there are regular staff meetings. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. Confirmation is required of the present management arrangements and some improvements to the safe working practices in the home are needed to ensure that service users are protected and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous inspection undertaken on July 13th 2007 there was an acting manager who had been in place for one week. However, during this inspection it was noted that the manager still had not registered with the CSCI. The registered person must ensure that an application to register the manager is completed and sent to the Commission as soon as possible. The manager was not available on the day of the inspection. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 23 The home has a number of systems regarding quality assurance. The area manager does a monthly management report, which covers the information required under Regulation 26 of the Care Home Regulations 2001. Copies are retained in the home and were seen during the course of this inspection. The inspector was told the home was in the process of sending out service satisfaction questionnaires and the advocate from Aylesbury Vale was due to visit the home during the week to support residents to complete them. There are regular house meetings and the inspector was told that there is an open door policy. The organisation requires the home to carry out a stakeholder audit each year. This includes a survey of residents, staff, relatives and professionals involved with the service. A range of health and safety checks are in place at the service and carried out on a daily, weekly or monthly basis. The fire alarm is tested on a weekly basis and recorded. The last visit undertaken by the Bucks and Milton Keynes Fire Authority was undertaken on 20/05/08 and it was recommended that the fire risk assessment be updated. There is a fire policy and a fire risk assessment in place dated 4/04/2007. This needs to be updated on an annual basis and will be a requirement of the report. Training records show that mandatory training is not up to date for all staff and this includes moving and handling, infection control and basic food hygiene training. Staff spoken to said that training events only occur once or twice a year and take place in locations that are difficult for staff to attend. The inspector was told that it can be difficult to book training events and maintain staffing levels in the home. A requirement has been issued for improvement in this area. Service reports are in place for PAT testing dated 10th July 2008, gas boiler certificate is dated 30th June 2008 and electrical installation is dated 4th June 2007. There is evidence of monthly health and safety checks and regular water temperature checks. COSHH sheets are up to date and accurate and storage of these are maintained securely. Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 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 3 X 3 X X 2 x Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 25 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 YA24 Regulation 23(2)(b) Requirement The registered person is required to ensure the repairs are made to the homes as identified in the main body of t he report. This must include the replacement of the hall and stairs carpet and the furniture in the conservatory is replaced. The registered person is required to ensure that staff complete accredited training in the safe handling of medicines. The registered person is required to ensure that the fire risk assessment is reviewed and updated annually. The registered person is required to ensure that mandatory training for all staff is up to date. This must include, first aid, basic food hygiene, fire training, moving and handling and infection control. Timescale for action 30/01/09 2 YA20 13 (2) 30/12/08 3 YA42 23(4) 30/10/08 4 YA42 18(1)( c ) 30/12/08 Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 26 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 YA6 YA14 Good Practice Recommendations It is recommended that a reduction of unnecessary information contained in care plans is completed that would make the care plans more user friendly. It is strongly recommended that that the registered persons conduct a review of activities so that residents, individually and collectively, have a wide and appropriate range to choose from and receive support from staff in accessing these. It is recommended that CRB’s dated 2003 and 2004 be renewed. 3 YA34 Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Haslerig Close (8) DS0000023040.V367471.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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