Inspection on 12/09/05 for Haddon (42a)

This inspection was carried out on 12th September 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Haddon (42a) 16/05/06

Haddon (42a) 08/03/05

Haddon (42a) 26/10/04

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 Haddon (42a) 42a Haddon Great Holm Milton Keynes MK8 9HP Lead Inspector Barbara Mulligan Announced 12 September 2005 9.30am th 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 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 Stationary 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 (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Haddon (42a) Address 42a Haddon, Great Holm, Milton Keynes, MK8 9HP Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01908 262860 MacIntryre Care Miss Karen Campbell Care Home 12 Category(ies) of Learning Disability (LD) registration, with number of places Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 29th June 2005 Brief Description of the Service: Set on the edge of Great Holm, no.42a Haddon, owned by Macintyre Care, is located within a campus style complex, in amongst private housing. It provides accommodation to adults with learning disabilities. 42a 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. 52a and no. 32a Haddon, the organisations day care services, a hall, a nursery and garden centre, a craft shop, a coffee shop, bakery and an administration office. 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. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over two days on the 12th and 13th September 2005. The visit consisted of discussions with the manager and care staff and a tour of the flats. Records, policies and procedures were also examined. A pre-inspection questionnaire was sent to the home prior to the inspection with comment cards to distribute to service users, relatives and health care professionals. The inspection officer was Barbara Mulligan. The Registered Manager of the home is Karen Campbell. What the service does well: What has improved since the last inspection? Care plans have been improved and these set out the action, which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Staffing levels have improved since the previous unannounced inspection, and this has been beneficial to the unit. A requirement was made during the previous announced inspection for the registered manager to update her mandatory training and it was pleasing to see that this had been complied with. Following the previous unannounced inspection a requirement was made that Regulation 26 visits are carried out on a monthly basis and that copies of these are held in the unit and sent to the commission. This had not been complied Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 6 until recently, when with the appointment of a new service manager they are now being undertaken. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides. Pictorial guidance is included to make both documents suitable for the people for whom the home is intended. Prospective service users have the opportunity to visit the home on an introductory basis, before making a decision to move there, ensuring that service users are able to make an informed choice about where they live. Each service user has an individual written statement of terms and conditions that is signed by service users or relative or relevant third party and the registered manager. EVIDENCE: The Service Users Guide is well presented and informative and this document covers all the necessary information as detailed in standard 1. The Statement of Purpose covers all areas as detailed in Schedule 1. No service users have been admitted to 42A Haddon during the previous twelve months. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 9 The assessment tool used by the home is called “Moving into Macintyre Care” and is very comprehensive and detailed. This is dated June 2003. Pictures are included alongside written information to enable the potential service users to understand the process. The home has a policy called “Moving in and Moving out guidelines”. This is dated June 2003. This gives details of trial visits to the home, day-to-day support service users can expect and details of how and when a review of the placement will occur. This is not in a different format suitable for service users. There is evidence from the care notes that the care-plans are working documents. All specialised services offered are accessed through the Learning Disabilities Community Team. Religious and social and/or cultural needs of service can be facilitated if requested. Service Users are informed about independent/self advocacy groups, and examples given were of Milton Keynes Advocacy and People First. Within the policy called “Moving in and Moving out guidelines” there is information regarding trial visits. This includes visiting the unit for a meal, staying overnight and a three-month settling in period. Following this the potential service user will have a review. If this is successful the service user will sign a contract/statement of terms and conditions. The unit does not accept emergency admissions. Service users contracts/statements of term and conditions were looked at during the visit. These covered all areas detailed in Standard 5. All contracts looked at have been updated and signed by service users. The home does not take emergency admissions nor is intermediate care offered. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 10 Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 Care planning documentation has improved and adequately provides staff with the information they need to satisfactorily meet service users needs. However, further work to combine both the essential lifestyle plans and personal care plans into one document is recommended to prevent duplication of information. EVIDENCE: Following the unannounced inspection a requirement was made that care plans contain a detailed action plan that sets out the action needed to be taken by staff, to ensure that all aspects of the service users needs are met. Work has been carried out in this area. However, there is a general care plan and an essential lifestyle plan. These both contain a lot of the same information and it is recommended that one document/care plan is used for each service user. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 standard(s) 11, 12, 13, 14, 15, 16 and 17. Links with the local community are good which support and enrich service users social and educational opportunities. Service users engage in appropriate leisure activities inside and outside of the home, allowing individuals to pursue their own interests and hobbies. Staff support service users to maintain family links and friendships inside and outside the home. The staff have a good understanding of the service users support needs. This is evident from the positive relationships, which have been formed between the staff and service users. Service users rights are respected and the daily routines of the home promote individual choice and freedom of movement. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 13 Service users have opportunities to maintain and develop social, emotional, communication and independent living skills through training carried out with the unit staff and day services staff. This includes menu planning, cookery, shopping and bus training. Some service users go to college to learn social skills and life skills. This includes literacy skills, money management, sex education, advocacy, fire training and relationship discussions. Most service users go to work and this tends to be mainly on site where there is a coffee shop, a craft shop and a nursery. 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. Service users are supported to continue with activities engaged in prior to entering the unit. Day services provide opportunities for further education and service users also attend the local college. The head of service said that service users take part in varied leisure activities and use local community facilities regularly. Examples given were the local leisure centre, 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. Relations with the neighbours are positive and no problems encountered. Service users have access to transport and use taxis, buses, dial-a-ride and trains and evidence was seen in the care plans and through discussions held with service users. Service users vote, and do so by proxy or by attending the local polling station on voting day. Staff recognise that time spent with service users outside the unit, including weekends and evenings, is part of their staff duties. Care plans show that service users are encouraged and supported to pursue their own interests and hobbies. Examples of these are football, swimming, dance, the cinema and horse riding. Where necessary, appropriately trained staff support and advice the service users. Each service user has access to a television and music systems Service users enjoy an annual holiday and those service users who do not wish to have an annual holiday enjoy day trips and weekend breaks. There are no restrictions about family and friends visiting. The unit has a lot of contact with families and friends of service users. Staff assist service users to make regular phone calls and to write letters to family and friends. Service users can chose whom they see and when, and can see visitors in their rooms and in private. Training and support is offered to service users about relationships and sex education and evidence was seen of this. All service users have keys to the front doors of their flats. The inspector was informed that staff will not enter the flats of service users unless there is some one at home. Each flat has its own doorbell in place. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 14 Service users open their own mail, and this is collected from the staff block where it is delivered. Staff help service users with reading and understanding the content of their mail, if help is required. Preferred terms of address are recorded in service users care plans. Interaction between staff and service users was observed and this was done with respect and in a manner that was appropriate to service users. During the visit, service users were observed to be alone in their rooms if that is their request or given the option to join in activities if they so wished. Housekeeping rotas are kept in flats and some of these were in picture form. They included such tasks as cooking the evening meal, washing up and cleaning. There are two service users who smoke and they are requested to smoke outside their flats. Service users choose their own menus at their flat meetings. Meals are offered three times a day and service users have access to snacks and drinks throughout the day. A record is kept of all meals provided. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 and 21. Personal support is offered in such a way as to promote and protect service users’ privacy, dignity and independence. The systems for the administration of medication are generally well managed protecting service users and ensuring their medication needs are met. However appropriate training of staff regarding the administration of medicines and rectal diazepam needs to be implemented. The physical, emotional and health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 16 Information regarding personal care is recorded in the service users care plans. Service users are very independent and they choose the times they wish to go to bed, bath, have their meals and take part in other activities. It is also evident through discussions with service users that clothes, hairstyles, make up and appearance are the service users choice. Service users receive additional support through the Learning Disabilities Community Team, where they can access physiotherapists, occupational therapists, speech therapists and other specialist service they may require. The unit operates a link worker system. The care plans set out in detail the service users preferred routine, likes and dislikes and partnerships with families, friends and relevant professionals outside of the unit. Visits to service users in their own flats take place in the privacy of their own rooms. Service users consent to medication is obtained and recorded in care plans. There are no individuals who self-administer their own medication and risk assessments are in place. One service user has epilepsy and occasionally requires a rectal stesolid. Staff receive training from The National Society for Epilepsy to do this. A requirement was made following the previous announced inspection that all staff be trained by a suitably qualified healthcare professional and that staff are then deemed competent by a suitably qualified healthcare professional and is a requirement of this report. A record of current medication is kept for each service user and these are accurate with no omissions. The home uses a monitored dosage system. Unused medication is disposed of via the supplying pharmacy. No controlled drugs are in use. Medication training for staff is carried out by Heads of Service. However, this training is not accredited and the organisation needs to give further serious consideration to more appropriate medication training. If a service user becomes ill, an assessment will be carried out, with the involvement of their family, and the service users wishes regarding terminal care and death will be discussed, and carried out. There is a set of guidelines regarding the death of a service user and this is dated April 2004. These guidelines include the expected, sudden or unexpected death of a service user and a last wishes questionnaire. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Staff have a good knowledge and understanding of Adult Protection issues which protect service users from abuse. EVIDENCE: The home use the Milton Keynes “Protecting Vulnerable Adults from Abuse” policy and a MacIntyre Care policy called “Protecting Vulnerable Adults from Abuse” dated September 2003 There are guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. There is a public disclosure policy dated Sept 2003. Staff spoken to are aware of how to report any suspected abuse and when it is necessary to disclose information given to them in confidence. All permanent staff receive training about Adult Abuse and this forms part of their induction. There is a Whistle Blowing policy and a Physical Intervention Policy dated September 2002. The homes policies regarding service users money and financial affairs ensure service users access to their money, valuables and safe storage is safe guarded. There is a gifts procedure that provides staff with guidelines about receiving personal gifts from service users. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 and 30. The standard of the environment within the flats is adequate, providing service users with an attractive and homely place to live. However, prompt attention to repairs and maintenance of the flats needs to be sustained, to ensure they remains safe, comfortable and accessible to the people living there. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. EVIDENCE: Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 19 42A Haddon contains 5 flats. Flat 42 has been turned into two flats so that two service users can live next to each other. The first flat of no 42 is occupied by a gentleman who was on leave during the visit. A female service user occupies the second flat of no 42. This flat is nicely decorated to the tastes of the occupant. Extra lighting and a pathway has been installed to the side of the flat for improved security. Flat 38 is nicely decorated, homely, bright and cheerful. Four gentlemen share this flat. The bath had been removed and replaced with a shower, however the shower has now been replaced again with an assisted bath at the request of the service users. The kitchen and flooring were still in need of replacing and this is a requirement of the report. Discussion with a relative of a service user who lives in flat 38 raised concerns about the general cleanliness of the flat. The organisation had recently employed part time domestic assistance for the three units but this post is now vacant having only been active for two weeks. During a visit to the flat the cleanliness was noted to be acceptable in the communal areas. All service users were out at work so personal bedrooms were not observed. However, concerns were raised about the cleanliness of flats during the previous announced inspection and it is recommended that the organisation give serious consideration to providing extra help to service users with the cleaning of flats. Flat 40 is nicely decorated, homely, bright and cheerful. Four gentlemen share this flat. Radiators in the bathroom, toilet and several bedrooms were extremely hot to touch and present a hazard to service users. A requirement was made that radiators are either covered or that the temperatures are lowered. This had not been completed at the time of the visit but the inspector did see evidence that this is due to take place shortly. This will be a requirement of this report. The kitchen requires replacing and is a requirement of the report. During the previous announced inspection it was observed that one service users bedroom was cold and had an offensive odour, one another bedroom was in need of redecoration and another required a thorough clean. Service users were out at work during the visit and bedroom doors were locked, so could not be inspected. However the head of service made assurances that this work had been complied with. The commission request written confirmation of how and when this work was completed and is a requirement of the report. Flat 34 is home to one service user and he showed the inspector round his flat. He has chosen to decorate the flat himself. The lounge and bedroom are decorated in a manner that is to the individual tastes. The kitchen was being refitted during the previous announced inspection and this was again decorated to the individual’s own personal taste. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 20 Flat 36 was decorated in a tasteful manner and was found to be homely and comfortable. The kitchen is due to be refurbished and new flooring installed. During the previous announced inspection concerns were raised regarding the length of time it takes for maintenance/repairs to be carried out. A recommendation was made that systems are in place to ensure that regular maintenance is undertaken, so that service users are not waiting for an unacceptable period of time. The head of service explained that outside contractors are being used at the present time, but plans are in place to provide an internal maintenance service. The unit offers all service users single room accommodation with en-suite hand basin. There are no service users who use wheelchairs and there are no shared rooms. One bedroom has en-suite facilities. Washing machines and tumble driers are sited mainly in the kitchen areas. The washing machines and tumble driers are domestic appliances. Service users do their own laundry with support from staff if needed. There is a policy for the control of infection, which includes dealing with spillages. There is no sluicing facility in the unit. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36. Staffing levels, although improving, remains low and staffing shortages do not offer consistency of care to the people using this service. The staff team are new and have not yet developed clarity of staff roles and responsibilities to ensure continuity of care. Most of the staff team are newly appointed and have not completed all necessary training to ensure they are competent and qualified to do their job ensuring that service users are cared for by skilled staff at all times. There are effective recruitment procedures in place to ensure service users are protected from harm. EVIDENCE: Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 22 Staff are still learning about the homes /organisations values, policies and procedures through staff training and induction and reading policies and procedures. The unit operates a link worker system, and link worker meetings are carried out with service users and their link workers. Through this system staff get to know and develop relationships with the service users they support and are able to meet their needs. It is evident that with numerous new members of staff, the team is in an early stage of development. This is a large draw on the head of service’s time and precludes her from her day-to-day role of managing the service. Serious consideration needs to be given to making the head of service supernumary to the staff on rota. The unit has no volunteers at the time of the inspection. All staff undertake an induction which provides the staff member with a personal development portfolio. During the previous announced inspection concerns were raised regarding the competencies and capabilities of a staff member observed during the inspection. These concerns remain the same and there is no evidence that the head of service has been supported to adequately deal with this. It is a requirement of the report that strategies are in place to support the head of service to manage this situation and ensure a resolution is forthcoming. It is requested that the commission be informed of the outcome of this particular issue. There are no staff members under the age of 18 yrs. Serious concerns were identified during the previous unannounced inspection on the 29th June and during a follow up visit a week later. At this time there were only three permanent staff members in post and the unit was in crisis. It is pleasing to see that staffing levels have improved. There are now six permanent staff members, (including the head of service) in post and two part time staff. A requirement was made during the previous unannounced inspection that the unit is fully staffed with ten full time and one part time staff members as agreed with the commission , and an action plan is sent to the commission within two weeks of how this will be achieved. The timescale for this 31/10/2005. The commission has received the action plan. Staffing levels will continue to be monitored regularly. A request was made to look at the files of the most recently employed care staff. The head of service explained that staff files will be kept at a central office. Visits to the central office will need to be undertaken to inspect staff files and they will not be available outside of office hours. It is a requirement of the report that suitable arrangements are made to make certain that personnel records are available for inspection at all times. Staff files looked at contain the necessary documentation as detailed in Schedule 2. There is a recruitment policy and procedure in place and an equal opportunities policy. These are comprehensive and informative. All staff appointments are subject to a six-month probationary period. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 23 There is evidence that staff undertake an induction programme and all mandatory training is covered. However, more than half of the staff team are new in post and undertaking relevant training. This means that the staff team as a whole are not fully qualified and trained to deliver care safely and competently. Newly appointed staff work alongside more experienced staff. This has proved difficult due to there only being three experienced staff members. There is evidence that care staff receive formal supervision monthly. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39 The unit do not regularly review aspects of its performance through a programme of self-review and consultations, which include seeking the views of, service users, staff and relatives. The registered manager has a good understanding of the areas in which the unit need to improve. However, support by the provider, for the manager and the unit in a time of crisis has been poor. EVIDENCE: Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 25 The head of service has had eight years experience working with Macintyre care. She has been the head of service for 42A Haddon since May 2004. Prior to this she completed an access to nursing course. The head of service is now registered as manager with the Commission. She has completed NVQ level 3 training and is undertaking NVQ level 4 at the present time. Following the previous announced inspection a requirement was made for the head of service to update her mandatory training and it was pleasing to see that this had been complied with. Examples of further training undertaken by the head of service include epilepsy training, the administration of stesolid training and managing challenging behaviour. Despite severe staffing shortages and on-going issues regarding of one service user from another, the head of service has worked hard to ensure the unit comply with the requirements set at the two previous inspections. The home has a complaints procedure in place and a whistle blowing policy, which enable staff and service users to voice concerns and affect the way in which the service is delivered. Macintyre Care has an equal opportunities policy in place that is accessible to all staff. There is Investors in Care report and a Portfolio of continuous improvement report. Both of these are updated annually. Internal audits include staff sickness, service users monies, staff training and accidents/incidents. The unit has not undertaken any service user surveys during the last twelve months. During discussion with a relative of a service user it was apparent that the organisation have no system to obtain the views of family, friends and advocates and of stakeholders in the community. This will be a requirement of the report. There was evidence that service users are informed about the announced inspection. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 2 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 2 2 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Haddon (42a) Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x x x 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 27 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 24, 28 Regulation 23 Requirement The registered provider is required to ensure that the kitchen, work tops and flooring are replaced in flat 38. The registered provider is required to ensure that radiators in the bathrooms, toilet and several bedrooms are either covered or the temperatures are lowered (Previous time-scale of 30/11/2004 not met.) The registered provider is required to ensure htat the kitchen, work tops and flooring in flat 40 be replaced. The registered manager is required to ensure that written confirmatin is sent to the commmission to confirm that requirements regarding service users bedrooms made at the previous announced inspection have been met. The registered provider is required to ensure that suitable arrangements are made to make certain that personnel records are available for inspection at all times. The registered provider is required to ensure that the views Timescale for action 30/03/06 2. 24 23 30/12/05 3. 24 23 30/03/06 4. 25 23 30/10/06 5. 41 Schedule 4 Reg 17.2 30/11/05 6. 39 12, 30/12/05 Page 28 Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 of family, friends and advocates and of stakeholders in the community are sought on how unit is achieving goals for service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 6 30 Good Practice Recommendations It is recommended that one document/care plan is in place for each service user. It is recommended that serious consideration is given to providing extra support for service users with the cleaning of flats. Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 Page 29 Commission for Social Care Inspection Cambridge House 8 Bell Business Park Smeaton Close Aylesbury, Buckinhamshire. 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 Haddon (42a) 20052009 42a Haddon X100023 AI Stage 5 S28414 V239084 H53.doc Version 1.40 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. 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!