Inspection on 03/01/08 for Haddon (32a)

This inspection was carried out on 3rd January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haddon (32a) 09/05/06

Haddon (32a) 01/11/05

Haddon (32a) 25/07/05

Haddon (32a) 14/02/05

Haddon (32a) 19/07/04

Haddon (32a) 08/12/03

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

CARE HOME ADULTS 18-65 Haddon (32a) 32a Haddon Great Holm Milton Keynes Bucks MK8 9HP Lead Inspector Barbara Mulligan Unannounced Inspection 3rd January 2008 09:50 Haddon (32a) DS0000048436.V357212.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 Haddon (32a) DS0000048436.V357212.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. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haddon (32a) Address 32a Haddon Great Holm Milton Keynes Bucks MK8 9HP 01908 262814 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 Mrs Claire Helen Dove Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Set on the edge of Great Holm, no.32a Haddon, owned by MacIntyre Care, is located within a campus style complex, in amongst private housing. It provides accommodation to adults with learning disabilities. 32a Haddon is situated within walking distance of the local shops, church and local pubs. The building itself contains five self contained flats and a small garden area. There is a further complex of buildings that comprise of no. 42a and no. 52a Haddon, the organisations day care services, a hall, a nursery and garden centre, a craft shop, a coffee shop, bakery. v The coffee shop and bakery occupy the corner of the site and this provides occupational opportunities for service users and enables local residents to visit the shop. The nursery, garden centre and craft shop also provide occupational activities for service users and are open to the public. The centre of Milton Keynes is close by offering a large shopping centre, cinema, a range of restaurants and recreational activities, cycle tracks and many other attractions. Service users are encouraged and supported to use public transport to which they have access. Fees range from £18000 to £39000 per year. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was conducted over the course of a day and covered all of the key National Minimum Standards for younger adults. Prior to the visit, a detailed self-assessment questionnaire was sent to the manager for completion. Information received by the Commission since the last inspection was also taken into account. No comment cards were received from people who use the service by the time the report was written. The inspection officer was Barbara Mulligan. The registered manager is Claire Dove. The inspection consisted of discussion with the manager and other staff, opportunities to meet with some service users, examination of some of the home’s required records, observation of practice and a tour of the premises. A key theme of the visit was how effectively the service meets needs arising from equality and diversity. Twenty-six of the National Minimum Standards for Younger Adults were assessed during this visit. Twenty-one of these are fully met and five are almost met. As a result of the inspection the home has received five requirements. The evidence seen and comments received indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. The manager, staff and service users are thanked for their co-operation and hospitality during this unannounced visit. What the service does well: Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 6 The flats are a nice and comfortable place to live. People who want to live at Great Holm have their needs assessed before they move in, to make sure the staff can meet the needs of the people who live there. The care plans tell the staff how to care for the people living in the flats. The staff makes sure that the people who live in the flats are safe when they go out and take part in activities. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 7 The people who live in the flats are good friends. The service provides good healthy meals for all the people who live there. The people who live in the flats and their friends and family, are supported to make their views known. There are health and safety checks carried out regularly in the flats to keep the people who live there safe. What has improved since the last inspection? Staff working in the home have received up to training. The numbers of staff on duty have improved to Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 8 make sure that staff no longer work alone. Monthly monitoring visits now take place regularly. What they could do better: This inspection at the home has shown 5 things need to be done to make it okay. Peoples changing health needs must be written in care plans so they can stay well. The records for medicines must be kept up to date and be fully completed. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 9 People know how to make a complaint, but the complaints policy needs to be updated. Staff know how to keep the people living at Great Holm safe, but the policy for protecting people needs to be updated. The home must keep all the important information and photos of all 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. The summary of this inspection report can be made available in other formats on request. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 10 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 Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. People who use the service have their needs thoroughly assessed prior to admission ensuring that staff are prepared for admission, and given opportunity to visit the home beforehand to ensure it meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up to date Service Users’ Guide and Statement of Purpose are in place at the unit, which details the scope and philosophy of the service and how it aims to meet people’s needs. These are in good order and easy to follow. There have not been any new admissions to the service in the past twelve months, according to information supplied prior to the inspection. However two people who use the service have been transferred from another MacIntyre care home. Each person using the service has a comprehensive needs assessment on file, which demonstrates that they have been involved in this process. The home does not take emergency admissions and is not registered to provide intermediate care. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Detailed care plans are in place, which adequately documents the care needs of people who use the service, and how these are to be met, within a risk assessment framework. People who use the service are enabled to make decisions and be as independent as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four people using the service was case tracked and their care plans were examined. Each file contains various care planning tools. For example in one file there is the “About Me and How to Support Me” corporate care plan tool, an “intimate care policy”, a “health action plan”, an “essential lifestyle plan” and a Person Centred Plan. Although this ensures that a lot of information is in place, there is a lot of duplicated information, the files are heavy and bulky and not user friendly. This may prevent them being used as working documents. A reduction of unnecessary information would make the care plans more user friendly and is recommended. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 13 The care plans examined by the inspector provide detailed guidance for staff to follow and are detailed and informative. Photographs of the individual are placed at the front of their files with information on their history. Copies of local authority community care plans and purchase orders were seen to be in place. Flat meetings are held between people who use the service and staff, to share and discuss any issues and pass on news. Minutes are kept of these and demonstrate that issues raised are managed appropriately. The registered manager said that link worker meetings are held with people using the service on a monthly basis. Minutes are kept of these meetings also, and these show that agreed actions are taking place to meet care needs. Additionally, a fortnightly people’s forum takes place, facilitated by an independent person which is open to all people who us the MacIntyre services at the Great Holm site. People who use the service were seen to make decisions during the inspection, such as what to make for lunch, what to but at the shops and arranging to see family at the weekend. Money is well managed for people who live at Great Holm. There are individual wallets kept secure and transaction sheets to record expenditure. Receipts are in place to verify purchases. Reports of the provider’s monitoring visits show that service users’ money is checked routinely as part of the visit, which is a good practice. Risk assessments were observed to be in place and these are signed and dated by the author. All of these show that they are reviewed and updated regularly. Examples of risk assessments seen include using a push bike, refusal to be weighed, rock climbing, use of hot water, self medication and swimming. Missing person procedures were in place in the event of anyone being absent from the home without notice and for staff to refer to, if need be. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. People who use the service have a varied and active lifestyle, which reflects their interests, and are supported to maintain family links and friendships inside and outside the home. Menus are developed by people who use the service with support from care staff that promotes independence and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was told that people who use the service are involved in a number of activities, mainly locally based at Great Holm, where there is a coffee shop, a craft shop and a nursery. On site there are opportunities for individuals to take part in craft, drama and computer classes. There is also opportunity for those that wish, to develop office skills and undertake a National Vocational Qualification working at the provider’s central headquarters. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 15 Records show that service users’ interests are taken into account when organising activities for them, whether as part of the day service provision or when at home. Some people who use the service go to college to learn social skills and life skills. This may include literacy skills, money management, sex education, advocacy, fire training and relationship discussions. One person was in employment at a local supermarket and another individual attends a selfadvocacy group via the day services. Care plans show the leisure activities that people who use the service are able to take part in. Examples seen include the local leisure centre, a local gym, cinema, shops, library, health centre and local pubs and restaurants. Many local residents and members of the public visit the coffee shop where service users are employed, and staff support the service users to become part of, and participate in, the local community. The inspector was informed that relations with the neighbours were positive and that there had been no problems encountered. Care plans show that people who use the service have access to transport and use taxis, buses, dial-a-ride and trains. The inspector was told that all the people living at 32A Haddon choose to vote and do so by proxy or by attending the local polling station on voting day. People who use the service were seen to have keys to their doors and had freedom to be alone in their rooms or in the communal areas. The inspector was informed, through discussions that there are no restrictions about family and friends visiting. People living at the site have a lot of contact with families and friends and this was seen recorded in care plans and Person Centred Plans. People who use the service said that staff help them to make regular phone calls and to write letters to family and friends. Several people have their own mobile telephones in addition to the payphones in the flats. The registered manager informed the inspector that service users can chose whom they see and when, and can see visitors in their rooms and in private. Each flat that was seen had its own menu drawn up by people who use the service and individual needs, such as diabetic meals, are being met. The registered manager said that individuals are weighed regularly and the inspector saw these recorded and risk assessments are in place for people who refuse to be weighed. Care plans show that at least two people who use the service have difficulties maintaining a healthy weight. Nutritional screening seen in care plans is not detailed. This is discussed further under Standard 18. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. People who use the service have their needs outlined within their individual plans, ensuring that the manner in which they are supported and cared for by staff is appropriate and promotes their preferences, but changing healthcare needs of people who use the service need to be recorded in care plans to ensure they receive the assistance they require. Medication practice needs further improvement through safer recording systems to ensure that safe procedures are consistently followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personal support is provided either in individual bedrooms or bathrooms. People who use the service are supported to choose when they like to go to bed, have a bath, have their meals and take part in other activities. This information is recorded in care plans and Person Centred Plans. . It is evident from the care plans that people who use the service are supported to choose their own clothes, hairstyles and make up. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 17 People who use the service have their personal and healthcare needs recorded in support plans. Records of health care appointments were being noted, showing that routine and specialist medical advice is sought. In one file looked at, the “health care action plan” was dated July 2005 and contained out of date information. For example, the person’s next of kin was recorded as their mother, with her phone number and address recorded. However their mother is now deceased. This document has not been reviewed since July 2005 and does not record the changing health needs of this individual. Another “health care action plan” was dated April 2006 and did not reflect the individual’s current situation. They have had difficulties maintaining a healthy weight. Under the “my eating” section of the document it records “no support needed” and usual weight as 14 stone. The present situation is quite different. The individual has gained approximately two stone and eleven pounds in weight and they are having difficulties maintaining a healthy diet. There is no current information on how to support this individual to maintain a healthy weight. A requirement has been issued for improvement in this area. Following the previous inspection it was identified that one individual had increased mobility needs and had been waiting for an assisted bath to be installed. It is pleasing to see that this has been completed. Staff provide support to people who use the service needing to attend outpatient and other appointments. The unit operates a link worker system. One person using the service was choosing to self-administer their own medication, with support from care staff. There is a risk assessment in place for this and is up to date and signed by the author. Since April 2007 the home has been using a Monitored Dosage System (MDS). The supplying pharmacist has visited the home once in December 2007 to advice on storage, records and safe practices. There were no out of date medications held in the flats of people using the service with a returns procedure in place. The inspector examined medication records and there are numerous omissions, mainly for creams and lotions. This was discussed with the registered manager and a requirement has been issued for an audit system to be put in place, to ensure that complete and accurate records are kept of all medication administered to people who use the service, and action must be taken when problems are identified. Staff training has been via the supplying pharmacist and training records demonstrate this. There are numerous hand-written entries on medication records that are not signed or dated. These must be signed by two staff and dated and this is strongly recommended. There is a new medication policy dated January 2007. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. Procedures for managing complaints and adult protection are in place but need some minor revision to ensure people have accurate information to hand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a corporate complaints procedure. This needs some revision as although produced in 2003 it refers to out of date legislation, The Registered Home Act of 1984, and is not explicit in informing complainants that the Commission may be approached directly if they have any concerns or complaints and the contact details. A requirement is made to address this. However, up to date details are evident in the Service Users Guide and Statement of Purpose that has been given to all individuals who use the service. Four complaints were noted in the pre-inspection self-assessment, one of which had been upheld. People who use the service or their representatives had made no complaints directly to the Commission. The complaints seen have been responded to within timescales and are well recorded. There are adult protection procedures in place. These refer to out of date legislation and refer staff to the “registering authority”. Updating is needed to amend the legislative background, if the policy is to mention this, and to make sure that staff know that they are to report adult protection matters to the Commission. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 19 There have been three adult protection referrals made in the past year, according to information supplied before the inspection. At the previous inspection a requirement was made for the staff team to undertake training in safeguarding/protecting adults from abuse. Records at the service showed that this had been attended to in all cases. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 29 and 30. Quality in this outcome area is good. A clean, comfortable and homely environment has been created for people who use the service, ensuring that they have appropriate surroundings in which to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service consists of five flats, numbered 24 to 32 Haddon in Great Holm. There are five flats that are divided into one, two, three and four bedroom flats. The staff office is separate to the flats although very close by. From Great Holm, service users have good access to the facilities within Milton Keynes city centre and there are good transport links. Four of the five flats were toured as part of this visit and people who live in the flats were asked permission by staff for entry. Many people who use the service were out at work on the day of the inspection. One person offered to show their room to the inspector. This had just been decorated in a colour of her choice and she was very pleased with Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 21 the results. Storage was highlighted as an issue at the previous inspection and extra cupboard space has been provided in some flats. New kitchens have been fitted in most of the flats and two assisted baths have been installed in two flats. Lounges in all flats are homely in appearance and looked bright and comfortable. In one lounge the people who live there have chosen to have a snooker table. The flats are generally clean with no odours. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Training records demonstrate that all staff have attended Infection Control training in the last twelve months. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 22 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 and 35. Quality in this outcome area is adequate. The staffing numbers and skill mix is adequate and improvements have been made in staff training to ensure that people who use the service benefit from staff who are who are competent to do their job. Recruitment records need to be available in the home for all care staff to demonstrate that all recruitments checks have been undertaken by the organisation and ensure people who use the service are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff on duty appeared confident in their roles. Progress is being made with NVQ training. At the time of the visit there was one relief staff member with NVQ level 3, a support worker with NVQ level 3, who is currently on maternity leave, the assistant manager has completed NVQ level 3 and the registered manager has competed NVQ level 4 training. At the previous inspection a requirement was issued that care staff are not rostered to work on their own at any time during the day shifts. The staff rota demonstrates that this has been complied with. A further requirement was issued for the unit to be adequately staffed, to allow care staff to attend Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 23 necessary training as needed without leaving the unit short of staff. Training records show that staff are up to date with all areas of training and the unit has been fully staffed. However one staff member has now gone on maternity leave and another staff member has just left employment. The registered manager needs to ensure that staffing numbers remain adequate to ensure that staff do not have to work on their own at any time and can attend training when required. It is noted that the organisation has a formal agreement with the Commission for it to hold centrally some specific staff recruitment documentation and maintain a signed checklist within the home. Four staff recruitment files were viewed at this inspection including those new to the service. The newest member of staff commenced in August 2007. The file kept in the office for this person did not contain evidence of a POVA or Criminal Records Bureau Check (CRB), no application form, references, photo or evidence of identification. The registered manager stated that she was still waiting for these documents to arrive from the central office. This is an unacceptable length of time for these documents to be sent to the registered manager and a requirement has been issued for improvement in this area. Two files looked at contain the necessary evidence of recruitment checks. The CRB checks are dated 2003. It is recommended that these are renewed. Copies of certificates from courses attended have been collated for each person working at the service. These demonstrate that all staff are up to date with basic food hygiene training, first aid training and fire safety training. Moving and handling training needs to be updated for five staff. The registered manager said that all newly employed care staff now undertakes a five day induction via Milton Keynes Council and this covers mandatory health and safety training. The inspector saw evidence of this for the newest staff member. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The home has implemented a quality assurance system but this needs to be strengthened and delivered more consistently to ensure the unit is being proactive in identifying issues that may effect the well being of people who use the service. The home has a registered manager ensuring continuity of care, and there are systems within the home that are used to ensure that health, safety and welfare of the people who use the service are protected and promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a registered manager who has been in post since 1993. She has attained National Vocational Qualification level 4; her post comes with a job description outlining duties and responsibilities. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 25 The registered manager reports to an external line manager who carries out her supervision monthly and undertakes monitoring visits on behalf of the provider. Examples of further training in the past twelve months include, equality and diversity, communication, medication training, first aid and inspirational management and recruitment. During the inspection there were satisfaction questionnaires that had been sent out to individuals who use the service. These were dated April 2006. At the previous inspection a request was made for a copy of the published results of the survey to be sent to the Commission. This had not been done and leaves the exercise open ended. Should a further exercise be carried out this year, it would be expected that a registered manager collate the findings as part of their professional role and share these with the people who took part and relevant parties. Following the previous inspection a requirement was issued for monthly monitoring visits to be carried out. It is pleasing to see that this has been complied with. These were looked at for the past five months and they follow a detailed format that shows speaking with staff and people who use the service is a regular feature of the visits, plus good practices such as examining a sample of individuals money and staff training records. There is a forum that is held twice a week and is facilitated by an independent person. This is open to all people who us the MacIntyre services at the Great Holm site. Flat meetings and link worker meetings take place on a regular basis and minutes are kept of these which were observed at the inspection. A range of health and safety checks are in place at the service and carried out on a daily, weekly or monthly basis. Following the previous inspection a requirement was issued for the fire risk assessment for the home. The fire risk assessment was looked at and is fully completed and is dated 26/06/07. Training records show that all care staff have received up to date fire training. The last visit by the fire authority was on the 16/01/07. Several requirements were issued. The inspector saw a letter that states the work has been completed. Weekly fire checks are carried out and recorded. Fire drills involving people who use the service were last carried out on 18/08/07 and 23/12/07. There is written evidence of water and fridge and freezer temperatures. PAT testing was last carried out on 4th and 5th September 2007. Following the previous inspection a requirement was issued that the servicing of all gas appliances is undertaken as soon as possible, or provide to the Commission evidence that this has been undertaken. The inspector saw a certificate for this dated 01/11/06. This needs to be carried out on an annual basis and this needs to be addressed. There is an Electrical Installation certificate dated 30/09/07. Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 3 X 3 X X 3 x Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation Requirement Timescale for action 30/03/08 2 YA20 3 YA22 4 YA23 12(1)(a)(b) The Registered Person is required to ensure that the changing health care needs of people using the service are recorded in care plans. 13(2) The registered person is 28/02/08 required to ensure that an auditing system be put in place, to ensure that complete and accurate records are kept of all medication administered to people who use the service, and action must be taken when problems are identified. 22 The registered person is 30/04/08 required to ensure that a revised complaints procedure is to be produced (with reference to current legislation if legislation is referred to) including the name, address and telephone number of the Commission. 13(6) The adult protection policy is to 30/04/08 be updated to reflect current legislation (if legislation is referred to) and to make explicit to staff that they are to report adult protection matters to the Commission. DS0000048436.V357212.R01.S.doc Version 5.2 Haddon (32a) Page 28 5 YA34 19 schedule 2 The registered person is required to ensure that recruitment records are maintained at the home and available for inspection purposes. 28/02/08 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 Refer to Standard YA6 YA20 YA34 Good Practice Recommendations It is recommended that a reduction of unnecessary information contained in care plans is completed which would make the care plans more user friendly. It is strongly recommended that all hand-written entries on medication records are dated and signed by two staff. It is recommended that all Criminal Bureau Checks completed in 2003 and 2004 are renewed to ensure people who use the service remain protected by the organisations recruitment practices . Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 29 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 Haddon (32a) DS0000048436.V357212.R01.S.doc Version 5.2 Page 30 - 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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