Inspection on 27/01/06 for 8 Haslerig Close

This inspection was carried out on 27th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 17 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 16/07/08

8 Haslerig Close 13/08/07

8 Haslerig Close 27/06/06

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 08/07/2008.

CARE HOME ADULTS 18-65 Haslerig Close (8) Harvey Road Aylesbury Bucks HP21 9PH Lead Inspector Gill Wooldridge Unannounced Inspection 27th January 2006 09:10 Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 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.V280870.R01.S.doc Version 5.1 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.V280870.R01.S.doc Version 5.1 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) Kingshouse@together-uk.org Together Working for Wellbeing Mr Emmanuel Tawiah Mensah 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.V280870.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2005 Brief Description of the Service: Haslerig Close (8) is a detached house in a quiet cul-de-sac on the outskirts of Aylesbury with local ameneties and public transport links, the home appears to be well integrated into the local community. The home provides twenty-four 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, formally the Mental Aftercare Association (MACA). There is an established staff team which is supported by bank and agency staff.The staff team liase with health proffessionals to ensure that residents receive the appropriate care. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 27th January 2006 from 9.10 a.m. until 13.40 p.m. with a follow-up meeting on the 30th January. A further visit took place on the 1st February 2006 with Rosemarie James, Regulation Manager, to discuss the condition of the kitchen with the proprietors representative and the landlord. The lead inspector, Gill Wooldridge, carried out the inspection. During the course of the inspection, the requirements and recommendations from previous inspections were discussed. The inspection consisted of a tour of parts of the building, gaining permission from residents to enter their bedrooms. Three care plans were studied and the care of these residents tracked. Staff training records and Medication Administration Record (MAR) sheets were also studied. Care staff were spoken to and time was spent in discussions with the manager and deputy manager. Interaction between staff and residents was observed and overheard. Residents were spoken to during the course of the inspection. What the service does well: The home has an established staff team with support from a small number of bank and agency staff. The staff team has a mix of skills and experience and has an understanding of the philosophy of the home encouraging independence, empowerment, respect and dignity. The staff team encourage residents independence and facilitate recreational and social activities. Newly purchased furniture has improved the communal areas and at least two bedrooms have been decorated, regular cleaning of these areas adds to the ambience. Management support is given to the home by the registered manager whose style of management facilitates improving the service delivery and promotes good practice, this was confirmed by staff. The home has tried to promote advocacy. There is a homely relaxed feel to the home. There was a relaxed, calm atmosphere and residents/clients and staff did not appear phased by the inspection. Interactions between residents/clients and staff were positive with humour and lots of smiles from residents/clients. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 6 Communication with other professionals supports the care of residents. This was confirmed by staff in handovers and what was recorded in residents records. Staff described having an approachable, supportive manager who has formalised supervision and team meetings which supports the care of residents. Staff have access to a confidential help line. What has improved since the last inspection? What they could do better: It is strongly recommended that the staff team develop links for residents, if that is their wish, such as advocates, befrienders and or volunteers. Medication procedures must be developed to include some more detail in two PRN management plans. Procedures must be followed and supported by staff competency checks and an increased audit system to eliminate any inconsistencies. The manager must ensure that all staff follow the home’s medication policy which should be developed further. A protocol for the administration of Movicol should be in place. The manager should request that the pharmacist re issue soluble aspirin so it can be dissolved before administration. Care plans need to be developed to include the residents present situation and must be a useful document for newly employed staff or agency staff and provide the detail of how support is to be actioned. All assessed needs must be supported by a care plan. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 7 Risk assessments must improve. Environment requirements set at the previous three inspections must be attended to. Failure to comply, may lead to the Commission considering enforcement action. It is acknowledged that the area manager has sent to the Commission an action Staff are reminded to be vigilant when handling residents money. The manager and proprietor should review staffing levels. A the frailty and age of residents indicates that they have higher needs. Emergency lighting must be tested monthly. The home must have a water chlorination certificate. The home’s fire risk assessment must be developed and include a risk assessment for the hold open devices and include that these are numbered and included on the tests already taking place. All documentation relating to the risk of fire from the fire department must be held on the premises. Quality audit systems must be developed. Accident recording must relate to risk assessments. A new accident book is advised. The wearing of staff keys visible to residents and staff entering the home without ringing the door bell should be discussed in staff meetings. Where there is a perceived restriction of liberty for example staff holding residents cigarettes, this must be reviewed in a multi disciplinary forum. All staff employed in the home must be competent, trained and experienced including agency staff. 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. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 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 Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Some information regarding a recent assessment was not available and may indicate that information sharing is dependent on verbal handovers by staff if this should break down there is a potential for residents’ health, social and personal care needs not being met. EVIDENCE: The home has had a recent admission in the last few months. The resident described being settled in his new home. The paper work seen was clear although the initial assessment in the residents previous home was not available and may have been held by the manager. This may indicate that information sharing is dependent on verbal handovers by staff if this should break down there is a potential for residents’ health, social and personal care needs not being met. The home’s assessment gave some clear information and was supported by information from the referrer. However, it is strongly recommended that the manager request a comprehensive risk assessment from the referrer to support the assessment process. A recent CPA was held although no minutes were received at the home. A brief outline was typed up which is noted as good practice. There was no apparent contract signed by the resident and there was apparently little choice for the resident regarding the home, although the resident described visiting the home before his stay. Staff described some good practice regarding the assessment process, this should Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 10 be supported by clear guidelines incorporating this good practice, including consultation with the other residents already living in the home. Residents physical and mental health needs are supported by health professionals in the wider community and how to access these services is clearly documented. This was described in records seen with many references to the GP, District Nurse or Community Psychiatric Nurse. At the visit on the 1st February a CPN was visiting the home. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 9. Care plans need to contain detailed information to ensure that any newly appointed staff and/or agency/ bank staff can refer to these documents to ensure that residents needs are met. All assessed needs must be recorded in a care plan. Risk assessments need to be reviewed regularly to ensure that any potential hazards or risks do not effect residents. EVIDENCE: There are some concerns regarding the content of some of the care plans viewed. This is balanced by the staff knowledge, who were able to describe residents care fully. However, all the care plans need to describe clearly staff actions, the level of support, prompting and approach needed. Staff need to evidence residents involvement in the process by obtaining their signatures or to record that they have refused, this was not always evident At the previous inspection, it was acknowledged that the care plan format was in transition. This new format must be supported by training for staff, ongoing support and an audit system which will facilitate an overall standard for the home. This was not evident, staff described that they had received no training Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 12 in care planning and it was not evident that there was an audit system in place. Residents files contained regular Care Programme Approach. Care plans included resident and key worker goals supported by quarterly/six monthly key working care plan reviews. One care plan indicated some good practice for example ‘when Mr X is unwell it is best to be direct and tell him that his behaviour is causing upset’. Constructive feedback which was described clearly would ensure any new or agency staff could work effectively with Mr X. There was also an updated document outlining how to manage Mr X’s behaviour this document had some clear detail. Records viewed did not always support the clear verbal information described by staff, which may lead to this information being lost in any verbal exchange or staff’s described knowledge. One care plan did not contain the resident’s presenting situation or describe how staff should support the resident. In a further residents file information indicated that the resident had bouts of depression, blackouts and needed specific support at night. These needs must be supported by care plans. Care plans were not all dated, or signed and some records had no manager or key workers signature and did not always indicate that the resident refused to sign. Staff described the recent admissions care plan as a developing document. This care plan must be more complete within 7 days of receipt of this report. The two risk assessments seen on file were dated 2003 this is unacceptable, Staff must review and include the detail discussed. Staff must ensure that risk assessments and care plans interrelate. Risk assessments relating to residents activities have been drawn up but need further development as discussed during the inspection. Risk assessment documentation needs to ensure resident independence and safety is maintained and residents and staff roles in supporting this. Residents moving and handling risk assessment must be reviewed regularly to ensure that they reflect the residents present situation. Residents were seen to be encouraged and supported to be involved in all aspects of their lives although this was not always supported by records seen. One resident was washing her bedroom net curtains. The point of motivation or this resident’s spontaneity must be included in her care plan. Any perceived restriction of liberty, for example, the holding of residents cigarettes, must be supported by a discussions held within a multi disciplinarily Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 13 process and records maintained for inspection purposes, encouraging the resident to be part of the process. Staff described that they were seeking advice on moving a resident whose physical needs the home were struggling to meet. Letters seen on file supported staff comments. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 & 12 Residents have the opportunity for personal development as they choose. Residents are able to choose a range of appropriate activities. EVIDENCE: Residents described social activities and trips out for coffee and into the town. Some residents attend local groups and clubs. Residents and staff described residents attending day centres and accessing the local community. Residents self determination is given a high priority by staff and residents often choose to spend time in their rooms or communal areas, smoking and watching the television. Although ongoing support for residents is low key it is supported by working at the residents pace on achievable goals indicated in care plans. Staff described encouraging residents to socialise and integrate within the local community and this was evident during the inspection. Points of motivation are often difficult for some residents. Staffing levels should be reviewed to promote further community access for residents. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 15 It is strongly recommended that the staff team facilitate befrienders, volunteers, and/or advocates to increase residents’ social contacts if they choose. Staff described clearly the importance of upholding residents’ rights. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 There are inconsistencies in staff practices in medication procedures, which have the potential to place residents at risk. EVIDENCE: Medication Administration Records (MAR) sheets showed some inconsistencies, these included scribbling out over an entry and leaving a gap. It was also noted that hand written entries on the (MAR) sheets were not supported by two staff signatures. It is acknowledged that the manager has sent all but two staff on a medication training course. The manager did produce competency checks for two staff who hadn’t received medication training. More frequent competency checks should take place. Staff must be reminded of their personal accountability and the importance of good recording practice and records must be maintained for inspection purposes. To improve staff practice and ensure residents safety the manager must audit staff practice and the MAR sheets more frequently. It is important that the home considers a programme of self-medication for residents or working towards this in the coming months. It is acknowledged some work has been done in this area however, this was discussed and should be developed further. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 17 PRN individual management plans were in place, some advice was given regarding two management plans. The other documents were clear and contained some good information. Staff confirmed that the residents GP reviewed medication regularly. Medication perceived as controlled drugs were counted and corresponded with records. It is strongly recommended that the home purchase a separate lockable box to safely store this medication. The manager must request soluble aspirin is dispensed separately to ensure that the aspirin can be dissolved before administration. It is strongly recommended that the manager develop a protocol for the administration of Movical. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 A clear awareness of adult protection protocol should ensure residents safety. Residents money is on the whole protected by good systems. EVIDENCE: The manager described a historic situation which could be concerning. The manager was advised of the Bucks Inter Agency Adult Protection Protocol and he is required to follow the inter agency procedure and report the matter to the residents care manager. It is strongly recommended that the manager regularly discusses adult protection with staff and residents in the appropriate forum. The manager must confirm that all staff are aware of their responsibility under the interagency protocol. All staff have recently undertaken adult protection training. Residents finances are supported by staff described practice however, the re was an observed a minimum discrepancy at the time of the inspection. Staff are reminded to be vigilant when handling residents money. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Shortfalls in the environment and health and safety issues have the potential to effect residents safety. EVIDENCE: The home is situated in a quiet cul-de-sac on the outskirts of Aylesbury close to local shops and a leisure centre with good transport links to the town. A requirement of the proprietor and manager is that they maintain the property to ensure that residents live in a homely comfortable and safe environment. There was some discussion around the previous requirements set at the previous inspections relating to the environment these are parts of the requirements set from previous inspections not met. • • The kitchen cupboards are to be repaired or replaced. Sealant must be replaced around the sink and edges of the kitchen units. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 20 • Bedroom 6 requires a carpet and bedside cabinet be replaced and window latches to be fitted. It is acknowledged that the home is awaiting stronger window latches to be purchased. Sealant around the shower in the downstairs bathroom needs replacing. The discolouring of the ceiling in the bathroom downstairs requires investigation and remedy. Grouting need replacing to tiles in the bathroom downstairs. • • • The condition of the kitchen has deteriorated and now shows signs of water damage on draws and cupboards and some base units, some cupboard doors need replacing a door handle is broken on one draw. Flaking paint was evident above the cooker hood and in a corner of the kitchen. The kitchen base/sink unit has some water damage. Sealant must be replaced. Tiles need regrouting in the kitchen. Pedal bins must be purchased to aid infection control. The proprietors representative confirmed at a meeting held at the home on the14th February 2006 with New Leaf the Landlord and the Inspector. A further meeting at the Commission took place in the afternoon. It is confirmed that this work will be given the highest priority. The proprietors representative had already sent to the Commission their action plan. However, timescales for completion would be appreciated to identify when the work will be completed. The proprietor and manager have ensured that call bells are fitted. However this must be reviewed as the system cannot meet residents needs. Staff confirmed that the call bell cannot be heard downstairs. It is acknowledged that the staff team try to motivate residents and that this can often be a difficult task. The manager and proprietor are required to tour the building ensuring that they enter every bedroom on a regular basis, gaining permission from service users is preferable. However, it may be necessary to insist on access as part of a formal agreement as necessary. Staff will continue to support residents in the upkeep of their bedrooms ensuring the environment does not pose a risk to health and safety of any resident. It is acknowledged that these improvements may take some time, however, written evidence of the attempts to address the work and motivate the service users will need to be kept for inspection purposes. To ensure the building is maintained and the safety of residents the manager and proprietors representative must tour the building monthly and maintain records for inspection purposes, this must ensure that all the maintenance, refurbishment and health and safety issues are identified and have a clear time scale for completion. It was evident that the manager tours the home regularly however, it is not evident that the proprietor representative tours the building. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 21 It is acknowledged that the proprietor and manager have been attempting to address these shortfalls with the housing association, however, limited progress has been made. The proprietor’s representative must tour the building regularly and produce an action plan with timescales to maintain the property this action plan must be sent to the Commission. The tour of the building must be recorded and actions to address any shortfalls with clear timescales must form part of the action plan. Records must be maintained in the home for inspection purposes. The proprietor must write to the Commission within 14 days of receiving this report to explain why these requirements have not been met. Failure to meet these requirements may lead to the Commission considering enforcement action. Following the inspection evidence was seen to demonstrated that the organisation had information that indicated that they had been informed that the kitchen would be completed by the landlord. It is acknowledged that the communal areas have benefited from the purchasing and regular cleaning of furniture. The shortfalls noted at this inspection are as follows: • • • The downstairs bathroom floor must have a deep clean. The shower chair must be fitted to the wall in the downstairs bathroom. Bedroom 8 must be spring cleaned and redecorated and the vanity unit must be replaced. A metal bin must be available in this bedroom. It is strongly recommended that an extractor fan be fitted. Cracks must be investigated and remedied in the hall, stairs and landing. The stairs, hall and landing must be redecorated. Bedroom 3 needs the ceiling painted. The curtains must be re hung in bedroom 6. The call bell must be replaced in the upstairs bathroom so that it can be heard downstairs and in the interim supported by a risk assessment. The mouldy sealant in one upstairs bathroom must be replaced; a missing tile must be replaced in the upstairs bathroom. Tiles must be replaced in the downstairs bathroom. The flaking paint in the wc must be investigated and remedied and then redecorated. The proprietor and manager must eliminate the odour in this area. The odour in bedroom 7 must be eliminated. The manager must purchase a washing machine within 7 days. Bedroom 6 must be redecorated. DS0000023040.V280870.R01.S.doc Version 5.1 Page 22 • • • • • • • • • • Haslerig Close (8) • • • • • • • • • • • • Bedroom 4 the vanity unit must be replaced or repaired Swing bins must be replaced by foot pedal bins in the kitchen and bathrooms to aid infection control. Flaking paint on window frames and between the walls and ceilings in a number of areas must be investigated and remedied. The sealant must be replaced in one upstairs bathroom. Bedroom 7 needs redecoration around the mirror. The kitchen ceiling appears to have had some water damage and this must be investigated and remedied. Flaking paint must be investigated above the cooker hood in the kitchen. Grouting must be replaced and sealant must be replaced in the kitchen. Tiles need re-grouting in the kitchen. Pedal bins must be purchased to aid infection control in the bathrooms and kitchen. Sealant needs to be replaced around the vanity unit in bedroom 6. The remaining bathroom floor upstairs must be replaced. It must be replaced with suitable water resealant non-slip flooring that is covered at the edges for easy and hygienic cleaning. Flaking paint on doorframes in bedrooms and in bathrooms and bedrooms between the wall and ceiling must be investigated and remedied. • Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 The use of agency staff distracts from the competent, qualified staff which may impact on the residents care. Staff training for the established team has been given a high priority which should benefit the care of residents. Recruitment of more staff should benefit the care of residents. Recruitment procedures appear robust which should protect residents. EVIDENCE: The established staff team have a good understanding of residents needs and have a clear understanding of their roles and responsibilities. However, it was evident when rushed staff are not always following the organisation’s policy regarding infection control or food handling. During the inspection and subsequent follow up visit, staff were seen wearing gloves in other areas of the home either before or after carrying out a care task. There is a rolling programme of training and staff have generally completed all mandatory training. One bank staff member had not completed a first aid course, the manager is required to ensure this staff member is competent in this area and must maintain records for inspection purposes. It is Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 24 acknowledged that the manager has written to the Commission stating that this has been completed. Information held on agency staff was limited to CRB numbers. However, the proprietors representative confirmed in writing to the Commission that appropriate checks had been undertaken for all agency staff. This information must be available during the inspection. The manager must ensure that all staff employed in the home are competent and qualified to support the residents living in the home. The proprietors representative confirmed in writing that agency staff had received training. Agency staff and the homes permanent staff practice of wearing gloves in the kitchen indicated their lack of knowledge regarding infection control, having apparently carried out a care task out in another part of the home. Food was apparently being defrosted in cold water in a sink and some meat was seen in the microwave. Staff must follow the homes policies and where necessary this must be supported by further training which was not evident at this inspection. Only one member of staff as been employed in the last year and this staff member file was studied three references were available along with a CRB. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Residents benefit from a well run home and a open and receptive staff team. Shortfalls in health and safety procedures may place residents at risk. Quality audit systems must be in place to support the residents care. EVIDENCE: The manager appears open and responsive to the inspection process. Some health and safety records were seen. A water chlorination certificate must be obtained and emergency lighting tests must take place monthly and be recorded monthly. Risk assessments for the door guards and a system for checking that the door guards close must be in place. The manager must confirm that he has responded to the fire officer’s letter of the 28th July 2005. The call bells fitted must be audible to staff when downstairs. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 26 Risk assessments for radiator not covered must be in place. The manager must ensure that all correspondence is held in the home and available for inspection purposes. The latest letter from the fire department was not available on the first day of the inspection. Regulation 26 visits do take place and reports are sent to the Commission. The proprietors representative must confirm in writing that she has permission from the Commission for these visits to be announced. The manager is reminded that any event under Regulation 37 any event that effects the well-being of a resident is to be reported to the Commission. An accident reporting system is in place however, the system is liable to fail as loose pieces of paper are stored in a plastic wallet. The accident book refers to staff and holds staff and residents accidents. It is strongly recommended that the manager develops an audit system for all accidents and incidents. The system of recording accidents must be supported by a clear procedure. It is not clear that there is a distinction between accident and incident recording. The manager must re affirm the homes policy and procedure to all staff. It is strongly recommended that the home has separate accident book for staff and residents. Quality audit systems were discussed and the manager and organisation need to involve residents in any quality audit system ensuring that there are clear outcomes to improve the service delivery. Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 27 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 X 2 2 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 1 X LIFESTYLES Standard No Score 11 2 12 2 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 3 X X 2 1 X Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 (a), (b) & (c) 15 Requirement The manager must ensure that all contact with prospective residents is recorded and held in the home. Care plans must reflect all assessed needs and reflect the residents present situation ensuring staff approach is described fully. The process of care planning must be supported by training and ongoing support for all staff. A quality audit system will support the process to ensure an overall standard for the home. Previous timescale 31/11/05 not met. Any perceived restriction of liberty must be supported by discussions held and reviewed in a multi disciplinary forum. Risk assessments must be reviewed regularly and focus on residents independence whilst supporting them if any danger. The manger must audit the MAR sheets more frequently. Address any practice issues and staff must be reminded of their accountability. The manager must check all staff DS0000023040.V280870.R01.S.doc Timescale for action 31/03/06 2 YA6 30/09/06 3 YA9 13 (4) 31/05/06 4 YA9 13 (4) 31/05/06 5 YA20 13 (2) 31/03/06 Haslerig Close (8) Version 5.1 Page 29 6 YA24 23 (2) (b) 7 YA24 23 (2) (b) 8 YA23 10 (1) (a) 9 YA35 18 (1) (a) 10 11 12 YA39 YA42 YA42 24 13 (4) 13 (4) 13 14 YA42 YA42 13 (4) 13 (4) competencies. Maintaining records for inspection purposes. Previous timescale31/8/05 not fully met. The proprietor and manager must address the shortfalls in the environment detailed in the standard noted at this inspection. The proprietor and manager must ensure that they maintain the property to ensure that residents live in a homely comfortable and safe environment. Previous timescale 31/9/05 not fully met. The proprietor must write to the commission explaining why this requirement has not been fully met. The manager must report all potential or actual adult protection issues to the lead authority. All staff must be aware of the Bucks Inter Agency Adult Protection Protocol. The manager must ensure that all staff employed in the home are aware of the organisation’s infection control procedure and food handling practice. Quality audit systems must be developed. The manager must obtain a water chlorination certificate. The manager must ensure that emergency lighting test are carried out and records maintained. A risk assessment for the door guards must be in place and supported by weekly checks. The call bell fitted must be replaced to ensure the device can meet residents needs. In the interim this must be supported by a risk assessment. DS0000023040.V280870.R01.S.doc 31/03/06 31/08/06 28/02/06 30/04/06 30/06/06 30/04/06 31/03/06 31/03/06 30/06/06 Haslerig Close (8) Version 5.1 Page 30 15 16 17 YA42 YA42 YA42 13 (4) 13 (4) 13 (4) Radiators not covered must be supported by a risk assessment. The manager must ensure that all correspondence from the fire department is held in the home. The accident reporting system must be reviewed. 31/03/06 28/02/06 31/03/06 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 YA2 Good Practice Recommendations It is strongly recommended that the manager incorporates the good practice described into the home’s assessments procedure and produce guidelines for staff to follow regarding any future assessment. It is strongly recommended that the manager requests a comprehensive risk assessment from the referer regarding any futures admission. It is strongly recommended that the staff team facilitates befrienders, volunteers and advocates to increase residents social contacts if they choose. It is strongly recommended that the manager and proprietor recruit staff to support residents with their chosen recreational activity. It is strongly recommended that the staff team consider developing a self medication system. It is strongly recommended that the manager reviews the storage of controlled drugs. It is strongly recommended that the manager has a regular agenda item in staff meetings to discuss adult protection. It is strongly recommended that the manager and proprietor increase staffing levels to support the residents care. 2 3 4 5 6 7 8 YA2 YA13 YA13 YA20 YA20 YA23 YA32 Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 Haslerig Close (8) DS0000023040.V280870.R01.S.doc Version 5.1 Page 32 - 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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