Inspection on 23/06/06 for Baxter Close (1)

This inspection was carried out on 23rd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 13 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) 22/11/07

Baxter Close (1) 18/01/07

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 OBE Lead Inspector Chris Schwarz Unannounced Inspection 23rd June 2006 10:50 Baxter Close (1) DS0000015080.V292667.R02.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 Baxter Close (1) DS0000015080.V292667.R02.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. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Baxter Close (1) Address 1 Baxter Close Crownhill Milton Keynes Bucks MK8 OBE 01908 262835 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) www.macintyrecharity.org MacIntyre Care Miss Amanda Parker Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 2 people with a learning disability. Date of last inspection 8th March 2006 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 £24,401.52 per annum to £ 44,110.04, according to information supplied with the questionnaire. Items such as toiletries, trips out and sundries would be additional charges to service users. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of two days and covered all of the key standards for younger adults. Prior to the visit, a questionnaire was sent to the home alongside comment cards for distribution to service users, relatives and visiting professionals. There were no replies from the comment cards. The inspection consisted of discussion with the manager and individual meetings with some of the staff team. There were opportunities to observe care practice and to meet with service users to gain their views. A tour of the premises and examination of some of the required records was also undertaken. At the end of the inspection, feedback was given to the manager. What the service does well: Service users are cared for by competent staff, to ensure that they receive the support they require. There was observed evidence of service users making everyday decisions. Service users have a range of activities and are part of the local community, providing stimulation and variety. Service users are enabled to have appropriate personal, family and sexual relationships, promoting their rights and maintaining important social contacts. Service users are encouraged to be as independent as possible, promoting their rights and responsibilities. Varied meals are available to service users to meet their nutritional needs. Records reflect that service users are enabled to attend a range of health care appointments, to meet their medical needs. Medication is being managed effectively, to ensure that service users receive the medicines they require. Needs arising from equality and diversity are well met. Adult protection measures are in place to ensure that service users are safeguarded against the risk of harm. Health and safety is given due attention overall. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Care plans need to be finalised in order that accurate and up-to-date records of service users’ needs are in place. Individual risk assessments need attention to ensure that up-to-date and adequate evaluations are in place to minimise risk of harm. Practice needs developing to show that regular consultation takes place with service users. The health care needs of service users are not adequately reflected in their files, which could mean that needs are not met. Optician appointments are needed, to ensure that there are no visual problems. Guidance on monitoring self-administration of medicines by service users is needed, to supplement the existing procedures. Complaints procedures are in place to listen to the views of service users although these are not accessible to all and there are no recent records of any issues raised by service users. Robust recruitment practice could not be demonstrated, which could mean that staff have not been appropriately vetted, placing service users at risk of harm. Mandatory training for staff has not been kept up-to-date, which could mean that staff do not have sufficient knowledge and skills to best meet care needs. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 7 Management arrangements have not been sufficient to ensure that the service has complied with required actions, which may have affected service users’ care. There is no evidence of quality assurance monitoring taking place by the provider, to ensure that service users receive the care they require. Fire safety needs to be supplemented to ensure that adequate precautions are in place. 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. Baxter Close (1) DS0000015080.V292667.R02.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 Baxter Close (1) DS0000015080.V292667.R02.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): EVIDENCE: There have not been any new admissions to the service therefore standard 2 was not assessed on this occasion. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans need to be finalised in order that accurate and up-to-date records of service users’ needs are in place. Individual risk assessments need attention to ensure that up-to-date and adequate evaluations are in place to minimise risk of harm. There is some evidence of decision making and this needs to be developed to show that regular consultation takes place with service users. EVIDENCE: A requirement made at the last inspection regarding care plans was being attended to although not fully met yet. On the first day of the inspection, staff on duty informed the inspector that care plans were not available at the home as they were being typed up following revision. Information that was available was out of date and some of it needed archiving as it related to past events. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 11 On the second day, when the manager was present, she demonstrated that there was a file with copies of the draft care plans readily available in the office, although it is concerning that staff seemed unaware of this which may reflect how much use is made of care plans. The one draft plan examined followed a person-centred approach although was written on behalf of the service user who had good verbal skills and was able to communicate effectively about his situation. Final versions may well incorporate service users’ views. Individual risk assessments had not been reviewed and revised as required at the last inspection, with most assessments originating from 2004. There were no assessments in respect of cross gender care and these should be included in the review and revision. Following an incident at the start of the year, the incident record sheet stated that a service user’s risk assessment needed to be revised but this had not been done. Additionally, an assessment relating to safety within the community had been rated as “major” risk but the guidance to reduce risk was not in proportion to this and needs attention. There was only one set of house meeting minutes for this calendar year for Marley Grove. These need to be held more regularly to demonstrate consultation with service users and involving them in decision making about the home. Observation of carers provided some evidence of day to day choices being offered, such as assistance to prepare meals and offering choices of drinks when service users returned from day services. Service users were being consulted about colour schemes for redecoration of bedrooms and had chosen how the refurbished kitchen in Marley Grove would be fitted out. Management of service users’ monies at Marley Grove was examined and found to be overall in good order, with receipts to explain transactions and record sheets for each person. A check of three wallets was made and each tallied with recorded balances. One receipt showed that a member of staff who has now left had used her own loyalty card alongside a service user’s purchase, contrary to good practice. It is recommended that staff be reminded that this is not acceptable. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have a range of activities and are part of the local community, providing stimulation and variety. Service users are enabled to have appropriate personal, family and sexual relationships, promoting their rights and maintaining important social contacts. Service users are encouraged to be as independent as possible, promoting their rights and responsibilities. Varied meals are available to service users to meet their nutritional needs. EVIDENCE: Each person attends day services during the week and seemed to enjoy the stimulation that this provided. Some of the service users were seen walking to nearby Great Holm to go to or return from day services, whilst some used motorised scooters and the minibus at Marley Grove. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 13 Discussions with service users and reading of daily reports showed that service users make use of community resources and have the city centre close by, with a bus stop at the end of the road. They are involved in their personal shopping and banking and take part in the everyday domestic chores. Daily notes provided evidence of different times of getting up and going to bed, depending upon what service users had to do the following day. Several have their own keys and make use of these and it was possible to see that staff did not open service users’ post. Service users confirmed that they have contact with family and friends and each property has a telephone. Two married couples are supported to live independently with assistance when they need it. Service users living in the Baxter Close properties have a range of catering skills and assistance from staff was offered if needed. One person was making a tomato and white wine sauce from scratch to pour over gnocchi and in another flat the occupants were preparing beef burgers, new potatoes and vegetables. The meal at Marley Grove was fish and chips, part of a four week menu that had been drawn up of service users’ favourite meals. The kitchen at Marley Grove was well stocked with a good range of fresh, frozen and dried goods. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health care needs of service users are not adequately reflected in their files, which could mean that needs are not met. A range of health care appointments is documented for each person, although optician appointments were not noted in the files examined. Medication is being managed effectively with guidance on monitoring selfadministration needed to supplement the existing procedures. EVIDENCE: A requirement made at the last inspection for health and medical needs to be indicated clearly in care plans had not been met. The files containing this type of information were found to be very cluttered with a mix of old and new information and in some cases loose pages. The requirement is repeated on this occasion. Records of medical appointments are being maintained for a range of care needs although evidence of optician appointments was missing in the sample Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 15 of files examined. Appointments should be arranged for eye checks to ensure that there are no problems here. Medication practice was in better shape. The cabinet was locked and secure and medication administration records were accurately maintained. Reference was made in the last report to development of guidelines on managing service users’ self-administration of medicines. This had not been done and a requirement is made for this to be attended to, to ensure that staff monitor sufficiently. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Complaints procedures are in place to listen to the views of service users although these are not accessible to all and there are no recent records of any issues raised by service users. Adult protection measures are in place to ensure that service users are safeguarded against the risk of harm. EVIDENCE: A central complaints procedure is in place although this format would not be understood by all of the people living at Baxter Close or Marley Grove. Service user friendly versions need to be developed to make sure that people know of their right to complain, and to whom. The complaints log showed no entries more recent than 2003. At the time of the inspection the inspector discussed with the manager whether this was an accurate picture, or whether staff are not recording issues that they have dealt with. A log should be maintained of complaints made by any service user, not just those formally written to the provider. The lack of access to the garden at 1 Baxter Close (now rectified) is an example which had not been recorded in the log. A requirement is made to ensure that service users have accessible complaints procedures and that an accurate log of complaints is maintained. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 17 Protection of Vulnerable Adults and public disclosure procedures are in place at the home. A few of the staff need to attend adult protection training to supplement these procedures. The Commission has not received any complaints about this service and is not aware of any adult protection concerns. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements have been made to the environment at 1 Baxter Close and Marley Grove to ensure that service users have comfortable surroundings. There is mostly good regard for cleanliness but caution is needed to ensure that service users are not placed at risk of harm where inattention to cleaning is viewed as service users’ choice. EVIDENCE: Improvement has been made to garden access at 1 Baxter Close with hand rails due to be fitted to finish the work off. Occupants of the property were pleased with the work that has taken place and this now means they can use their garden. Their home is well presented and homely and has the necessary adaptations for people with disabilities. A leak in the kitchen was waiting to be repaired but did not seem to be causing major disruption. Marley Grove has a new kitchen which looks clean, modern and attractive and provides ample storage and improved fridge/freezer and dish washing facilities. A separate hand washing sink has been added and the main sink is heightBaxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 19 adjustable so that service users can use it. The laundry was clean and in good order, with cleaning products safely locked away and a new sink added in here too. New carpet has been fitted in the lounge, hallway and office and looks smart. Redecoration of one bedroom has taken place and the remaining two are to be done. The bathroom had been professionally cleaned and floor seals re-done since the last inspection and there was toilet roll, paper towels and hand wash where needed. The home has a Parker bath, shower and adapted toilet and ramped access into the garden. The garden needs a little attention to remove weeds in between paving stones and to provide some interest. 15 and 15A Baxter Close are self-contained properties like number one. Discussion took place with the manager about the amount of support service users receive to keep these properties tidy and to guard against health and safety hazards. In one of the properties, hazards were noticed in the kitchen which if left could present risks to the people living there. A sensible balance has to be obtained to promote service user independence whilst ensuring that they are not placed at risk from harm; staff need to be providing this support with service users if they cannot or are reluctant to do this themselves. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Robust recruitment practice could not be demonstrated, which could mean that staff have not been appropriately vetted, placing service users at risk of harm. Mandatory training for staff has not been kept up-to-date, which could mean that staff do not have sufficient knowledge and skills to best meet care needs. Service users are cared for by competent staff, to ensure that they receive the support they require. EVIDENCE: The recruitment files of two newer members of staff were requested but there was no documentation within the home. Information faxed to the Commission from the central office later on provided evidence only of Criminal Records Bureau clearance and uptake of references, not the full range of required checks. Training records showed a varied picture of mandatory training. Some refresher courses were booked where training had expired although the gap between expiry and renewal was excessive. For example, the manager last attended first aid training in 2001 and is booked for the three year update in Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 21 September this year. Another person last attended food handling and hygiene in 1997 and is booked to go again in October this year, another who attended the same course in October 2002 is also booked for an update in 2006. Moving and handling, which should be an annually attended course, was last attended in January 2004 by one person. Training for three people who need Protection of Vulnerable Adults updates is being looked into. The manager is undertaking National Vocational Qualification level 4. The senior support worker has attained National Vocational Qualification level 3, one of the support workers has started level 3 and a newer member of staff is about to commence level 3. None of the staff team was under the age of 21. Staff have a mix of skills, attributes and working backgrounds and observed interaction between them and service users was good. Staff spoken with described a good sense of teamwork at the home; staff meetings have been held three times so far this calendar year. The manager’s attention was drawn to one member of staff’s style of writing daily reports, which is not always wholly respectful of service users. A reminder to staff generally as part of a team meeting about the importance of professional record keeping is recommended. A requirement for the provider to review staffing levels had not been undertaken and is repeated for attention. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Management arrangements have not been sufficient to ensure that the service has complied with required actions, which may have affected service users’ care. There is no evidence of quality assurance monitoring taking place by the provider, to ensure that service users receive the care they require. Health and safety is given due attention overall but fire safety needs to be supplemented to ensure that adequate precautions are in place. EVIDENCE: The manager had returned from maternity leave five weeks before the inspection; during her time away from the home acting management arrangements were in place. Three requirements made at the time of the March inspection should have received attention in that time, and a fourth fully Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 23 met rather than partially, and it is disappointing that this was not the case. Supervision and appraisal of the staff team also fell by the wayside and is now being picked up by the manager. There was no evidence in the home of monitoring visits by the provider this calendar year and no reports have been forwarded to the Commission. This was also raised as a concern at the December 2005 inspection and the requirement made at that time is not being complied with. Various health and safety checks are undertaken of the properties, such as fridge and freezer temperatures, hot water temperatures and fire safety precautions. Some gaps were evident to weekly alarm tests in Marley Grove for the start of the year and a requirement is made to ensure that these are carried out each week. Servicing of the system had been regularly undertaken. The last visit by the fire officer was in 2004 and only referred to Marley Grove in the subsequent letter. The manager is asked to contact the fire officer to check that the domestic fire precautions in place in two of the Baxter Close properties are sufficient. Generic and fire risk assessments were in place and up-to-date. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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 x 2 N/a 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 1 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 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 2 2 2 x 1 x 1 x x 2 x Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 25 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 YA6 Regulation 15 Requirement That urgent attention is paid to putting into place up to date and comprehensive care plans for all service users and to ensuring reviews both take place and accurate records are maintained of their outcomes. Previous timescale of 31/03/06 partially met. That service user files are audited and updated to ensure they contain relevant and up to date information on service users. Previous timescale of 31/03/06 not met. Timescale for action 01/09/06 2. YA41 17(1) 01/09/06 3. YA9 13(4) 4. YA19 13 That individual risk assessments 01/09/06 on service users are reviewed and revised as necessary. Previous timescale of 31/03/06 not met. That as part of the required 01/09/06 updating of care plans attention is paid to ensuring clearer indication of service users’ health and medical care needs. Previous timescale of 31/03/06 not met. DS0000015080.V292667.R02.S.doc Version 5.1 Page 26 Baxter Close (1) 5 6 YA19 YA20 13(1)b 13(2) 7 YA22 22(2) & schedule 4 10(1) 13(4) 8 YA30 9 10 11 YA34 YA35 YA33 19 18(1)c(1) 18(1)(a) 12 YA39 26 13 YA42 23(4) Optician appointments are to be arranged for service users. Guidance on management of service users’ who selfadminister medicines is to be produced. Service users have accessible complaints procedures and that an accurate log of complaints is maintained. Support is to be provided in the Baxter Close properties to ensure that service users are not placed at risk from harm due to health and safety hazards. Evidence of the full range of recruitment checks must be available within the office. Mandatory training is to be brought up-to-date and maintained as such for all staff. That MacIntyre Care undertakes a formal review of the staffing levels required to adequately meet the needs of service users in the three separate units and provides a copy of the findings and intended actions in response to CSCI. Previous timescale of 30/04/06 not met. Monitoring visits are to be undertaken by the provider at least monthly and copies of reports made available at the home and forwarded to the Commission. Previous timescale of 31/01/06 not met. Fire safety is to be improved by: a) ensuring that weekly tests of the alarm system are consistently carried out. b) contacting the fire officer to verify that arrangements in place in 15/15A Baxter Close are adequate. DS0000015080.V292667.R02.S.doc 01/09/06 01/09/06 01/09/06 15/07/06 15/07/06 01/11/06 01/09/06 15/07/06 01/08/06 Baxter Close (1) Version 5.1 Page 27 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 3 4 Refer to Standard YA7 YA7 YA24 YA32 Good Practice Recommendations Regular service user meetings are to be held to demonstrate consultation with service users. Staff are to be reminded that use of their own shop loyalty cards for service users’ purchases is not acceptable. Weeding is needed to the paved areas of the garden and the addition of some colourful areas of interest would be advantageous. Staff are to be reminded about the importance of professional record keeping. Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 Page 28 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 Baxter Close (1) DS0000015080.V292667.R02.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!