Inspection on 22/11/07 for Baxter Close (1)

This inspection was carried out on 22nd November 2007.

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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Baxter Close (1) 07/11/08

Baxter Close (1) 18/01/07

Baxter Close (1) 23/06/06

Baxter Close (1) 08/03/06

Baxter Close (1) 19/12/05

Baxter Close (1) 03/02/05

Baxter Close (1) 18/10/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Baxter Close (1) 1 Baxter Close Crownhill Milton Keynes Bucks MK8 0BE Lead Inspector Maureen Richards Unannounced Inspection 22nd November 2007 09:45 Baxter Close (1) DS0000015080.V339219.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 Baxter Close (1) DS0000015080.V339219.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. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baxter Close (1) Address 1 Baxter Close Crownhill Milton Keynes Bucks MK8 0BE 01908 260005 01908 695643 reception@macintyrecharity.org www.macintyrecharity.org MacIntyre Care 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) Mrs Amanda Anstey Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 2 people with a learning disability. Date of last inspection 18th January 2007 Brief Description of the Service: Numbers 1 and 15, Baxter Close and 6, Marley Grove are three separately registered services located in Crownhill, Milton Keynes. They form a small service group providing accommodation and support to nine adult service users with learning disabilities. The homes are located within a short walking distance of each other in a small close in an area with reasonably good public transport to the city centre. There is a corner shop at the end of the road. The service is part of the MacIntyre Care organisation, an established provider of care for people with learning disabilities. At the time of the inspection the residents of Baxter Close included two married couples. The group of homes is managed from Marley Grove, which also provides accommodation for three service users requiring higher levels of support. The staff team works as one group, flexibly covering the needs of service users in all the three settings, rather than being specifically allocated to one or another. Together, Marley Grove and Baxter Close aim to enable people with learning disabilities to live as independent lives as possible. Please note that although the three units are currently separately registered they are all included in the scope of this one inspection report, which has been replicated for each of the three separate services. Fees range from £21,159 to £29,093 per annum. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over the course of a day with a follow up visit for 2 hours on a second day. The day included inspection of 6 Marley Grove and 1 and 15 Baxters Close which is managed from Marley Grove and have the same administration systems in place. The inspection covered all of the key National Minimum Standards for younger adults. Service users attend day services each day and as a result the home is unstaffed for periods of the day. Therefore the home was given 24 hours notice of the inspection to ensure that a member of staff was available for the inspection. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion and comment cards were sent to service users, relatives and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussion with the acting senior and support staff, opportunities to meet with service users, examination of some of the home’s required records, observation of practice and a tour of the premises. On day 2 the inspection included discussion with the registered manager. Feedback on the inspection findings and areas needing improvement was given to the staff during and at the end of the inspection. The staff and service users are thanked for their co-operation and hospitality during this announced visit. What the service does well: The home has an admissions procedure in place although this has not been tested, as there has been no admissions to the home in the past twelve months. Service user plans are specific, detailed and informative to enable staff to meet service users needs in a safe and consistent manner. Service users cultural and religious needs are identified which supports equality and diversity for individuals. Service users are supported to maintain their independence and develop skills to assist them to live in the community with staff support as required. Service users are supported to have a varied and weekly programme of day centre activities including work placements Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 6 Contact with family and friends is maintained to promote social links. Systems and procedures are in place to deal with complaints and to ensure the protection of service users from abuse. New staff are inducted into the home and shadow experienced staff prior to working unsupervised on shift. Staff are appropriately supervised and feel supported in their role. Some documentation has been developed in a user friendly format and as appropriate for individuals. This continues to be developed on. Service users and relatives are happy with the care provided which promotes independence but with supervision and support available from staff. Staff are approachable, knowledgeable and confident in their roles. What has improved since the last inspection? What they could do better: Service user plans must include up to date risk assessments to ensure the safety and well being of individuals. Service user plans must make reference to guidance from other professionals so that all staff are working to the guidance. Medication practices must improve in relation to the use of homely remedies to ensure the safety of service users. Staffing levels must be reviewed to ensure that enough staff are on duty at peak times to meet service users needs throughout the service. The home must be decorated and refurbished to an acceptable standard to ensure that service users live in a safe and well maintained environment. Repairs must be responded to within an acceptable time frame. Equipment must be repaired or replaced to ensure the safety of service users. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 7 The Organisation should consider how relatives, professionals and funding authorities could be consulted as part of their annual quality audit of the service. Evidence of full recruitment checks for all staff must be maintained at the home to ensure the safety of service users. New staff and relief staff must have the required mandatory training before commencing work in an unsupervised capacity. 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. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. The home has an admissions procedure in place which ensures that the home is able to meet individual assessed needs, although this has not been tested as there has been no new admissions to the home in the past 12 months. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the information supplied on the Annual Quality Assurance Assessment document, there has not been any new admissions to the service in the past twelve months. Staff on duty confirmed this. However at the previous inspection it was assessed that this standard was met. The self Annual Quality Assurance assessment document outlines that MacIntyre has a comprehensive assessment document called Getting to Know You which is completed with the Service User and fully involves their family and other significant members in their circle of support. This ensures that individuals are suitably assessed and are provided with a service that suits them and meets their needs. The home indicates that they ensure that by following the Moving into MacIntyre procedures any transition into a Service is completed at a pace that best suits the individual an dthe others Service Users living within the Services. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 10 Transition consists of visits, planned meals, social activities, overnight stays and anything else that is required on an individual basis to ensure a smooth transition. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. Detailed and specific care plans are in place, which adequately document service users’ needs and how these are to be met, risk assessments need to be kept under review to support this and to promote the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service user plans were viewed, one from each of the services being inspected on the day. The care plan for the service user at this service had been developed in a person centred plan. The care plan was informative and specific and outlined the support required with physical, emotional, health and personal care needs, communication, day services and leisure activities, religion and cultural needs, managing finances, accessing the community, meals and other domestic chores to promote independence and develop social skills. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 12 Service users plans included personal details and contact details for the individual, information on where they lived, important people in their lives and their morning and evening guidelines. It is recommended that the plans are further developed to include the service users name on each page, a date of implementation and a date of review of the plan with evidence of discussion with the service user. Service users live in their own homes with planned support from staff and make their own decisions and choices in relation to most aspects of their lives. Staff support as necessary as outlined within person centred plan. The service users at 1 Baxter Close are a married couple with varying levels of independence and ability and the service user plan seen reflect this. The annual quality assurance assessment outlines that each service user has a linkworker and that the linkworker works closely with the individual to assist in identifying needs and choices through meetings, 1:1 sessions, annual reviews and day to day working. Care plans seen showed evidence of reviews but no records of one to one meetings. Service user plans included a series of risk assessments in relation to personal care, medical and health needs, relationships and emotional support, use of transport, finances and vulnerability in the community. The risk assessments were last reviewed in September 2006 and are now over due for review to ensure that all risks are identified and appropriately managed. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. Service users are supported to have a varied, active and independent lifestyle which reflects their interests, provides them with nourishing meals and allows them to have contact with family, friends and the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the service users have a full weekly programme of day services activities which include work placements, education and training. The service users living in this service do not want to engage in leisure activities. The annual quality assurance assessment outlines that service Users involve their families when they wish in their Annual Review meetings and plans. Comments received from relatives inidcate that they are kept informed of what is happening and are involved in their relatives care as approriate. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 14 The service user plan made reference to family involvement and service users can choose whom they allow into their home. The service user plan outline the level of support required by the individual to promote their independence and freedom of movement. Service users live in their own homes and as a result staff ring the doorbell and make themselves known to the service user. The service user makes the decision as to whom they allow into their home. Staff were observed to be respectful of the service users home and their surroundings. Service user plans outline the support required with housekeeping tasks but as service users live in their own homes they don’t always allow staff to support them with tasks or see the need to do specific household tasks. Staff support the individuals with their weekly food plan, food shopping and cooking. The service users decide on a daily basis want they want to eat and staff plan with service users what time they would like their meal to enable staff to be available to cover both services. Staff take the lead role in preparation of the evening meal for the individuals living in this service. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. The health and personal care needs of people living at the home are met however improvements are required to medication practices to further safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user plan made reference to the support required in meeting personal care needs. Service users have a linkworker at the home. Staff confirmed that they are responsible for liaising with other disciplines in relation to that person including regular reviews with day services. Annual review records seen support this. Annual reviews reports are developed in a user friendly format and as a result are more accessible to service users. Service user plans outlined the support required with meeting health needs and support to attend appointments There was evidence of healthcare screening with records maintained of the outcome of health appointments with Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 16 Dentists, Opticians, Podiatrists, General Practitioners, Speech and Language therapist and other specialist as required for individuals. A recommendation was made at the previous inspection that the Organisation should purchase a set of scales, which can be utilised as a resource for all of it services. Staff confirmed that this has been made available at the day services. The service user plan included an assessment and recommendations from the speech and language therapist. The service user plan made reference to support with meals but did not make reference to the guidance from the speech and language therapist. Staff were aware that they had to follow the guidance from the speech and language therapist but the care plan must be updated to reflect this. None of the service users in 1 Baxter Close self medicate and named staff are responsible for administering medication to service users. However this list needs to be updated to include the new staff member and acting senior. The medication is stored in a locked cabinet situated in the office. The home uses a monitored dosage system and printed medication records. Records of drug administration were found to be in good order with no gaps evident alongside prescribed dose times. It was noted the home had no controlled drugs at the time of this visit .The home has a record of disposal of medication back to the pharmacy. The medication records indicate that some service users take regular homely remedies for example cod liver oil, cold flu beechams. The medication policy outlines that homely remedies what has been agreed can be administered. However there is no evidence of what has been agreed and by whom. Therefore this must be addressed. New staff confirmed that they are assessed and deemed competent to administer medication. Medication assessments records for new staff member confirmed this. Some staff have attended medication training and other staff have been identified to go on this training. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. Systems are in place to ensure service users views are listened to and acted on and to safeguard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance assessment document outlines that no complaints have been received in the last twelve months. The complaints log seen at the home confirms this. No complaints have been made directly to the Commission by service users or their representatives about this service. Service user meeting minutes indicate that service users are asked if they have any complaints and their response noted. Service users and families indicated they knew how to make a complaint and the majority of feedback indicates that the service responds appropriately to concerns raised. The Annual Quality Assurance assessment document outlines that there have been no safeguarding referrals. Staff on duty were clear of their responsibility in reporting safeguarding issues and a copy of the interagency procedure was available for reference if required. Training records indicate that all staff have attended safeguarding of vulnerable adults training. Baxter Close (1) DS0000015080.V339219.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): 24,30 Quality in this outcome area is poor. Areas of the home are in need of refurbishment and redecoration to enable service users to live in a safe, well maintained and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Maintenance of the property is the responsibility of a Housing Association, with staff responsible for supporting service users with the cleanliness of the home. 1 Baxter Close is a 2 bedroom bungalow with a sitting/ dining room, separate kitchen, laundry , bathroom and toilet. Requirements were made at the previous inspection that the Organisation was required to ensure that the kitchen and flooring at 1 Baxter Close is replaced with suitable and functional fittings. The timescale for meeting this requirement was the 16th August 2007. This has not been complied with. The kitchen has not been replaced and the flooring in the kitchen floor is lifting in particular around the sink. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 19 The loose plaster in the kitchen and toilet had been repaired but was awaiting decoration and further cracks were noted by the rear laundry door and in the bathroom ceiling. A requirement was made at the previous inspection that the Organisation are required to ensure the internal environment is repaired and decorated to provide a suitably comfortable and homely living space for service users to enjoy. The timescale for meeting this requirement was the 16th August 2007 and has not been fully complied with. The manager confirmed that the Housing Association has carried out an audit of the property but have refused to carry out all of the work set as requirements at the last inspection. The Organisation must address this in line with the management agreement with the Housing Association to bring the home up to the requirements of a Registered service. The bath seat in the bath has a series of small cracks and this must be repaired or replaced to ensure the safety of service users. The home was generally untidy. Staff confirmed that they continue to work with service users in supporting them to keep their home cleaned to an acceptable level. Baxter Close (1) DS0000015080.V339219.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): 32,33,34,35,36 Quality in this outcome area is poor. Staffing levels are not sufficient to meet service users needs, new staff and relief staff have not got the required mandatory training and some recruitment practices are unsafe which potentially put service users at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff confirmed that they are working towards a National Vocational Qualification and one of those staff members was being assessed during the inspection. A further two staff have confirmed they are to be enrolled on the course and one of the new staff members have obtained her national Vocational Qualification. Staff were observed to be accessible to and comfortable with service users. Staff confirmed that they had the skills and training to do the job expected of them. Some staff attended specialist training in autism and makaton in 2005/06 with training in dsyphagia and epilepsy in 2007. Specialist training should be included as part of the annual training programme to continue to develop staff skills and awareness. No comment cards have been received from other professionals but staff confirmed that they have developed good working relationships with other Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 21 professionals. This was confirmed by the observation of telephone calls to other disciplines during the inspection. The home has recently appointed two support staff and a member of staff from another service has taken on the role of an acting senior. The rota seen indicate that there is two staff on duty each morning and afternoon shift with one staff providing care to the service users at Marley Grove and the other staff member providing support to the service users in 1 and 15 Baxter’s Close. The home is unstaffed at periods during the week when the service users are out at day services which allows for more flexibility with the rota. There is one staff member on duty at night who provides sleep in cover at Marley and would deal with any calls from Baxters. Staff are aware that they cannot leave Marley at night but would use the on call rota to get back up support if required for any of the Baxter services. A requirement was made at the previous inspection that the Organisation ensure staffing provided at 1 Baxter Close is reviewed to reflect the care needs of the most dependent service user at times preferred by this service user. Some progress have been made in addressing this requirement and staffing levels have been increased for the morning shift. The staff confirmed that the staffing levels are sufficient in the morning but that one staff member in each of the services in the evening make it difficult to meet service users needs at a time they would like. As identified under standard 13 staffing levels do not allow for individual one to one activities and service users at Marley Grove would have to go out as group, choose not to go or plan leisure activities in advance. This is unacceptable and must be fully addressed. The home do not use agency to cover vacancies and rely on their own staff and regular relief staff who know the service users to cover the shifts. It is hoped that the recruitment of two new support staff will address some of those. difficulties. A requirement was made at the previous inspection that the Organisation must cease providing support to service users at Stoney Stratford supported living service. Staff confirmed this had now ceased. Comments and feedback received from relatives and service users include that “they wish there was more staff” , “would be nice if there was less turnover of staff , on the other hand maybe the variety of personalities is good” Four staff files were viewed. The files seen included a checklist to indicate that two references and a Criminal Records Bureau check had been carried out prior to commencing work at the home. The files seen included various copies of identification for the individual. The home had no confirmation of recruitment checks for one of the relief staff working at the home. This member of staff work unsupervised in supporting service users and this must be addressed as a priority. During the inspection the National Vocational Assessor who is an ex member of staff from the home made arrangements to take a service user out to a leisure activity at the weekend. This is something she does regularly on a voluntary basis. The home had no documentation to confirm that this staff Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 22 member had the required pre employment checks. This must be made available. The manager confirmed that service users are involved in the recruitment process however no evidence was available to support this. This should be developed on. Staff training records indicate that the staff have the required mandatory training, however new staff have not got the required mandatory even though one new staff member is working unsupervised in supporting service users either at Marley Grove or Baxters Close. Therefore it is essential she has food hygiene, first aid ,manual handling and fire safety training as a matter of priority to support her in this role and to ensure the safety of service users. The home has no confirmation of training for one of the relief staff working at the home in an unsupervised capacity and this must be made available to ensure that this individual have up to date mandatory training. New staff are inducted into their role and induction records for the new staff member confirm this. New staff shadow experienced staff in working with service users and this was confirmed by staff and was evident from the rota. All staff spoken with confirmed that they feel supported in their roles. Regular supervision is planned in advance and scheduled on the rota. Regular team meetings take place and minutes of team meetings seen confirm this. Staff confirmed that they are encouraged to contribute to the team meetings. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 42 Quality in this outcome area is adequate. The home is generally well managed with systems in place to monitor the quality of care, however some health and safety practices must improve and compliance with requirements to ensure the health and safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager holds the National Vocational Qualifcation level 4 Registered Managers award. In the annual quality assurance documentation she has outlined that she has enrolled on the National Vocational Qualifcation level 4 in Health & Social Care award at a local college. Staff confirmed that they feel the home is well managed and that the manager is supportive and approachable. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 24 Three requirements from the previous inspection have not been complied with and a number of requirements have resulted from this inspection. The manager must ensure that these are addressed within the agreed timescale. Monthly monitoring of the home takes place and Regulation 26 reports were available at the home to confirm this. Staff on duty were clear of who the service manager was should they need to contact her. The Annual Quality Assurance documentation outlines that the Head of Service and Area Manager complete monthly financial and budget checks to ensure that all monies are accounted for correctly and finances are not being abused. The organisation carries out a “Big Respect” audit. The report indicates that this audit is carried out over two days with time spent with service users observiing and recording staff practices.This audit does not include feedback or input from relatives, other professionals or stakeholders and the organisation should consider how this could be developed. New staff have not got the required mandatory training but one staff member is working unsupervised either at Marley’s/ Baxter’s. There is no confirmation of mandatory training for relief staff. Health and safety checks including servicng of equipment are carried out at the home and records are maintained at Marley Grove to support this. Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 25 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 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 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 1 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 3 x x 3 x Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 26 Yes 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 YA9 Regulation 13 Requirement The manager must ensure that all service users plans include up to date risk assessments in relation to the management of identified individual risks. Service user plans must make reference to guidance from other professionals so that all staff are working to those guidelines. The manager must ensure that confirmation have been obtained from the prescribing General Practitioner that homely remedies administered by staff do not interact with individuals prescribed medication. A requirement is made to the Organisation to ensure staffing provided at 1 Baxter Close is reviewed to reflect the care needs of the most dependent service user at times preferred by this service user. (Previous timescale of 16/05/07 not met) The Organisation is required to ensure the kitchen and flooring at 1 Baxter Close is replaced with suitable and functional fittings. DS0000015080.V339219.R01.S.doc Timescale for action 31/01/08 2 YA19 15 31/01/08 3 YA20 13 31/01/08 4 YA16 YA33 18 31/01/08 5 YA24 23 (2) b 29/02/08 Baxter Close (1) Version 5.2 Page 27 6 YA24 23 (2) b 7 8 YA24 YA24 23 23 9 YA34 19 10 YA35 13 & 18 (Previous timescale of 16/08/07 not met) The Organisation are required to ensure the internal environment is repaired and decorated to provide a suitably comfortable and homely living space for service users to enjoy. (Previous timescale of 16/08/07 not met) The bath seat must be repaired or replaced. The organisation must ensure that a programme of renewal and redecoration is agreed with the Housing Association for each of the registered properties and that systems are in place for a speedy response to repairs. Evidence of recruitment checks for relief staff and ex staff working in a voluntary basis must be maintained at the home. New staff and relief staff must have the required mandatory training before working on shift in an unsupervised capacity. 29/02/08 31/12/07 29/02/08 31/12/07 31/12/07 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 YA6 Good Practice Recommendations It is recommended that the service user plans are further developed to include the service users name at the top of the page, a date of implementation and a date of review of the plan with evidence of discussion with the service user. The organisation should consider how relatives, professionals and stakeholders can be consulted as part of an annual quality audit. 2. YA39 Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Baxter Close (1) DS0000015080.V339219.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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