Inspection on 16/05/06 for Haddon (42a)

This inspection was carried out on 16th May 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haddon (42a) 12/09/05

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 Unannounced Inspection 16th May 2006 09:30 DS0000028414.V290165.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000028414.V290165.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000028414.V290165.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Haddon (42a) Address 42a Haddon Great Holm Milton Keynes MK8 9HP 01908 262860 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 Karen Campbell Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000028414.V290165.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 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. Fees range from £ 22,000 to £39,000 per year. DS0000028414.V290165.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 16th May 2006 at 9.30am on a Tuesday morning. The visit consisted of discussions with service users, support staff and the registered manager, records, policies and procedures were examined and a tour of the premises was undertaken. The inspection officer is Ms. Barbara Mulligan. The registered manager is Karen Campbell. Twenty-eight of the National Minimum Standards were assessed during this visit. Twenty-two of these are fully met and six almost met. As a result of the inspection the home has received eleven requirements. Service users, both those interviewed and those who responded to the survey expressed a high level of satisfaction with the care received from support staff. However, comments received from relatives expressed dissatisfaction that the parents meetings had stopped, with the conditions of the living environment and with staffing levels. 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. The inspector would like to thank the registered manager, the staff team and service users for their cooperation and assistance during this inspection. What the service does well: Individuals are encouraged to lead independent lives and there are varied and numerous opportunities for service users to undertake employment, further education and day care activities. Individuals are encouraged to personalise their flats and individual rooms with their own personal belongings. Service users receive good healthcare support via regular routine consultations. Medication is well managed in the home with relevant procedures in place for the administration of medicines. The staff team are motivated, undertaking relevant training and working towards their National Vocational Qualifications. Risk assessments are detailed and thorough. These cover the risks associated with assisting with medication and other health related activities. DS0000028414.V290165.R01.S.doc Version 5.1 Page 6 There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. What has improved since the last inspection? What they could do better: There are several on-going issues with the environment that need attention. These include: a) the kitchen and flooring in flat 40 is replaced. b) the sealed unit window, in the patio door of flat 40, is either repaired or replaced. c) the Patio area outside flat 40 is made safe. d) the kitchen and flooring in flat 36 is replaced. e) the bathroom in flat 36 is replaced. f) toilet and bathroom in flat 40 are redecorated following the removal of radiators. The unit need to maintain evidence of all recruitment checks for staff, as detailed in schedule 2. Relief staff need to be up to date with all necessary training. The registered provider is required to supply copies of gas servicing appliances to the Commission. Risk assessments for hot water outlets need to be reviewed and action recorded. Accounts for service users monies are audited on an annual basis. DS0000028414.V290165.R01.S.doc Version 5.1 Page 7 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. DS0000028414.V290165.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000028414.V290165.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. All service users have a written, individual service contract ensuring that there is an understanding of the homes terms and conditions. EVIDENCE: One service user has been admitted to the unit since the previous announced inspection on 13th September 2005. A detailed and comprehensive needs assessment has been completed for this individual and the assessment tool demonstrates that the service user has been involved in this process. There have been no other admissions to the unit. The assessment tool is called “Moving into Macintyre Care” and is comprehensive and detailed. This is dated June 2003. Pictures are included alongside written information to enable the potential service users to understand the process. All service users have a signed contract/statements of term and conditions and these cover all areas detailed in Standard 5. The unit does not take emergency admissions nor is intermediate care offered. DS0000028414.V290165.R01.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 good. This judgement has been made using available evidence including a visit to this service. Care planning documentation has improved and adequately provides staff with the information they need to satisfactorily meet service users needs. Support staff enable service users to make decisions in relation to their own lives, providing information, assistance and support to maintain their independence. Service users are supported to take responsible risks within the context of individual risk assessments and risk management strategies that ensure service users can have independent lifestyles. EVIDENCE: It is the responsibility of the link workers to draw up the plan of care, for each service user, and to review these on a six monthly basis. A random selection of service user plans were examined during the inspection and it is pleasing to see that files have been reviewed and now reflect the changing needs and personal goals for service users. Plans of care demonstrate that all aspects of the health, personal and social care needs of individuals are met. DS0000028414.V290165.R01.S.doc Version 5.1 Page 11 Risk assessments were observed in regard to service users who self-administer their own medication, service users who can manage their own money and cannot manage their own money and travelling independently. Other risk assessments in place cover service users activities, road safety and household tasks. Service users have monthly flat meetings and this was confirmed in discussions with service users spoken to during the visit. Minutes are kept and these were looked at. These demonstrate that service users have the opportunity to make decisions about their lives and how choices are made. Each individual has a bank account and their benefits are paid into their own personal accounts. The registered manager stated that she has not known the unit to have its accounts for service users monies audited and this will be a requirement of the report under standard 43. There is a service users forum that individuals can attend which is held on a fortnightly basis. This is used to discuss any issues the service users feel are important. This is also an opportunity for service users to have an input into the organisations policies and procedures. DS0000028414.V290165.R01.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 this service. Service users are able to access a wide range of amenities which meet their social, leisure and spiritual needs. The unit promotes ‘flexible’ visiting and the daily routines of the home promote individual choice, providing service users with the ability to be as independent as their needs allow. Service users are supported to develop their own menus and participate in some cooking tasks, which promotes independence and choice while at the same time reinforcing independent living skills. EVIDENCE: DS0000028414.V290165.R01.S.doc Version 5.1 Page 13 Day services provide opportunities for further education. Examples given to the inspector include training courses on literacy, computer skills, railway and vehicle, sports, filming and science. There is adequate staff support for service users to enable ample opportunities for social inclusion. Most service users go to work and this may be on site, where there is a coffee shop, a bakery and a nursery. Service users take part in varied leisure activities and use local community facilities regularly. Examples given are the local leisure centre, cinema, shops, library, health centre and local pubs and restaurants. One service user attends a local Weight Watchers Group and one service user who is of the Jewish Faith is supported to attend the Synagogue. 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 have access to transport and use taxis, buses, dial-a-ride and trains. Individuals vote, and do so by proxy or by attending the local polling station on voting day. There are no restrictions about family and friends visiting. This is detailed in the Service Users Guide. Service users spoken to confirmed that their friends and family visit them and are able to stay. Many service users have their own mobile phones. It is pleasing to be informed that a parent’s forum is due to recommence, ensuring the views of family, friends and advocates and of stakeholders in the community are allowed to be aired and taken into account. All service users have keys to the front doors of their flats and each flat has its own doorbell. Service users open their own mail, and this is collected from the staff block where it is delivered. Staff support 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 during the inspection and this is done with respect and in a manner that is appropriate to service users. Service users spoken to said that staff are “ good “ and they help me”. New housekeeping rotas are kept in individual’s flats. These show the service user in a photo undertaking the task they are to carry out. The inspector was told that these have helped service users to carry out household task without prompting from staff. These include such tasks as cooking the evening meal, washing up and cleaning. 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. DS0000028414.V290165.R01.S.doc Version 5.1 Page 14 Service users are weighed regularly and this is recorded in their care plans. One service user refuses to be weighed on a regular basis and there is a risk assessment in place. DS0000028414.V290165.R01.S.doc Version 5.1 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 the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal and healthcare support for service users is good and the systems for the administration of medication are generally well managed, protecting service users and ensuring their personal and healthcare needs are appropriately met. EVIDENCE: 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. DS0000028414.V290165.R01.S.doc Version 5.1 Page 16 Visits to service users by health care professionals take place in the privacy of their own rooms. There is evidence on file of the healthcare support available to service users and it is clear that routine appointments are attended in line with NHS entitlements and all initiatives recorded. Each service user has a MacIntyre health care action plan. Service users visit their G.P. on a needs only basis. Chiropody services are accessed locally. Specialist services such as physiotherapy, occupational therapy and speech therapy can be accessed via a referral through the G.P. or via the Community Team for People with Learning Disabilities. Staff provide support to service users needing to attend outpatient and other appointments. The unit operates a link worker system. Service users consent to medication is obtained and recorded in care plans. A record of current medication is kept for each service user and these are accurate with no omissions found. The home uses a monitored dosage system. Unused medication is disposed of via the supplying pharmacy. No controlled drugs are in use. Medication training is no longer carried out by the registered managers but is now being undertaken by a local pharmacy. DS0000028414.V290165.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. There are systems in place that enable service users, staff and stakeholders to make comments about the quality of the service in a non-judgemental manner. Staff have a good knowledge and understanding of Adult Protection issues which protect service users from abuse. EVIDENCE: DS0000028414.V290165.R01.S.doc Version 5.1 Page 18 There is a complaints procedure dated March 2003. This is in pictorial/photo form in the staff office and in individual flats. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. This includes information on how to refer a complaint to the Commission. The unit has a dedicated book for the recording of complaints. The unit has received no complaints since January 2006. All complaints are reviewed monthly and these are sent to the organisations central office. The unit 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 are also aware of when it would be necessary to disclose information given to them in confidence. During discussions with care staff, and following examination of training records it was evident that one staff member who commenced employment in January 2006 needs to undertake POVA training. It is strongly recommended that this is undertaken within six months of employment. There is a Whistle Blowing policy and a Physical Intervention Policy dated September 2002. The organisations 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 gift procedure that provides staff with guidelines about receiving personal gifts from service users. DS0000028414.V290165.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the flats is good, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness in the flats has improved, meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: DS0000028414.V290165.R01.S.doc Version 5.1 Page 20 42A Haddon contains 5 flats. Flat 42: has been turned into two single flats. A gentleman who was at home having lunch occupies the first flat of no 42. The flat is decorated to the tastes of the occupant. A female service user occupies the second flat of no 42. This flat is nicely decorated and homely. Extra lighting and a pathway have been installed to the side of the flat for improved security. The inspector was informed that a new, more secure front door is due to be installed in the very near future. 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. Two service users were at home during the visit. The inspector was invited to observe two bedrooms. These were personalised and decorated to the individual tastes of service users. Following the previous report a requirement was made for the kitchen and the flooring to be replaced and it is pleasing to see that this has been complied with. Service users home for lunch were kind enough to show the inspector the new kitchen. One service user spoken to said, “I like our new kitchen, its smart”. Flat 40: is nicely decorated, homely, bright and cheerful. Four gentlemen share this flat. It is pleasing to see that the radiators in the bathroom and toilet have been either removed or covered. Where these have been removed the walls now need redecorating. The kitchen requires replacing and was a requirement of the previous inspection report. This will remain a requirement of this report. Most service users were out at work during the visit but two individuals were happy to show the inspector their bedrooms. These were personalised and homely. One room was very cluttered and the service user said he would like a bigger bedroom. The window, in one of the patio doors in the lounge is a sealed unit. This has become very stained and it is not possible to see clearly through the window. This needs to be repaired or replaced. There is a small patio area for this flat at the top of a flight of stairs. This area has become unsafe with the small slabs being uneven and many are broken. This is a definite trip hazard to service users and staff and needs to be made safe as soon as possible. This will be a requirement of the report. Flat 34: is home to one service user and 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 has been refitted and this was again decorated to the individual’s own personal taste. The service user said, “ I chose the tiles for the kitchen. I like the colour blue”. DS0000028414.V290165.R01.S.doc Version 5.1 Page 21 Flat 36: was decorated in a tasteful manner and was found to be homely and comfortable. The kitchen was due to be refurbished and new flooring installed at the previous inspection. This has not been completed yet and will remain a requirement of this report. The lounge is tastefully decorated and homely. The bathroom needs to be replaced and redecorated. The unit offers all service users single room accommodation with en-suite hand basin. Domestic washing machines and tumble driers are sited mainly in the kitchen areas. 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. DS0000028414.V290165.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. There are effective recruitment procedures in place to ensure service users are protected from harm. However, not all files contain the appropriate evidence to demonstrate that all recruitments checks have been undertaken. There is a staff training and development programme that ensures staff fulfil the aims of the home and meet the changing needs of service users. However, access to this training is difficult and the registered proprietor needs to ensure that relief staff receive the necessary training, ensuring that service users are cared for by skilled staff at all times. EVIDENCE: A request was made to look at files for the most recently employed support staff. Original documentation for staff is kept a central office and this is to be the practice of the organisation. Of the files looked at one did not contain evidence that two references have been obtained. The unit needs to maintain evidence that all necessary recruitment checks have been undertaken. This was a requirement of the previous report and will remain a requirement of this report. DS0000028414.V290165.R01.S.doc Version 5.1 Page 23 There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. Staff then complete CWPLD training. Further training for staff includes First Aid, Basic Food Hygiene, Moving and Handling and Fire Awareness. Training records show that staff are up to date with mandatory training except a relief staff member who needs to update her mandatory training. This is a requirement of the report. DS0000028414.V290165.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 and 43. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The home has implemented a quality assurance system but this needs to be strengthened and delivered more consistently to ensure the home is being proactive in identifying issues that may effect the well being of services users. Overall health and safety procedures are not being adequately maintained. Mandatory training needs to be updated for relief staff. The overall management of the home ensures the effectiveness, financial viability and accountability of the home. However, systems need to be implemented to audit service users monies. EVIDENCE: DS0000028414.V290165.R01.S.doc Version 5.1 Page 25 The registered manager has eight years experience working with Macintyre care. She has been the manager for 42A Haddon since May 2004. Prior to this she completed an access to nursing course. She has completed NVQ level 3 training and is undertaking her Registered Managers Award at the present time. Examples of further training undertaken by the registered manager include risk assessment training, investigation and disciplinary hearings and mandatory training. The registered manager has the overall responsibility for ensuring the homes written aims and objectives are achieved, the homes budget is properly managed, policies and procedures are implemented, and certificates are displayed and that the home complies with the Care Standards Regulations. Internal audits include staff sickness, service users monies, staff training, accidents/incidents, service users support plans, NVQ monitoring forms are used, risk assessments and agency monitoring. The unit has recently sent out a service satisfaction questionnaire and these are evident in service user files. Information from these questionnaires has been sent to the service manager and the inspector requests that a copy of the published results is sent to the Commission. Feedback is also obtained from service users through flat meetings and link worker meetings. Minutes of these meetings are maintained and observed. Regulation 26 visits are being undertaken monthly and the Commission receives copies of these. A questionnaire has recently been sent to relatives prior to a relatives/stakeholders meeting due to be held on 20th May 2006. Several comments received by the Commission, via comments cards, indicate that relatives and service user representatives are concerned that the relatives meetings have ceased. It is pleasing to see that they are now due to recommence. Fire Safety Records were looked at. The unit’s fire risk assessment has been reviewed and updated as necessary. Records seen of weekly fire alarm testing, emergency lighting checks, regular servicing reports of fire equipment are up to date and accurate. There is a record of monthly fire evacuations and these are carried out with service users. Training records show that the staff team are up to date with Fire training, Moving and Handling training, first Aid and Basic Food Hygiene training, except for the relief staff member. This has been made a requirement of the report. Support staff should not be preparing or assisting service users to prepare food until Basic Food Hygiene training has been completed. The unit has no service certificates for gas appliances. The registered manager said that this was completed in November 2005 but the unit has not received the certificates. The inspector requests that copies of these are sent to the Commission and is a requirement of the report. Hot water is not thermostatically controlled, but hot water outlets are risk assessed and tested weekly. However, records were observed and show that DS0000028414.V290165.R01.S.doc Version 5.1 Page 26 water temperatures have been regularly recorded between 60ºC and 70ºc. This has been recorded from service users from bedroom sinks. There is no remedial action recorded in risk assessments and it is a requirement of the report that the risk assessments for hot water outlets are reviewed and action recorded. PAT testing is carried out annually and this was last carried out in flat 34 on 21/03/06 and the remaining flats in September 2005. A Health & Safety manual is available for staff. This is detailed and informative and attempts have been made to ensure this file is user friendly and contains a picture guide. Records were seen of accidents and incidents and these are monitored on a monthly basis. There are data sheets and COSHH risk assessments in place. There are insurance certificates on display in the home as per standard 43. The registered manager receives regular training, supervision and appraisal. In discussions with the registered manager about the systems in place to deal with service users money, she said that she has not known the unit to have its accounts for service users monies audited and this will be a requirement of the report. DS0000028414.V290165.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 2 2 DS0000028414.V290165.R01.S.doc Version 5.1 Page 28 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 YA24 Regulation 23 Requirement It is a requirement of the report that the toilet and bathroom in flat 40 are redecorated following the removal of radiators. The registered provider is required to ensure that the sealed unit window, in the patio door of flat 40, is either repaired or replaced. The registered provider is required to ensure that the Patio area outside flat 40 is made safe. The registered provider is required to ensure that the kitchen and flooring in flat 36 is replaced. The registered provider is required to ensure that the bathroom in flat 36 is replaced. The registered provider is required to ensure that the unit maintain evidence of all recruitment checks for staff, as detailed in schedule 2. The registered manager is required to ensure that relief staff are up to date with all mandatory training. The registered provider is DS0000028414.V290165.R01.S.doc Timescale for action 30/09/06 2 YA24 23 30/11/06 3 YA24 23 30/07/06 4 YA24 23 30/12/06 5 6 YA24 YA34 23 17 Schedule 4 30/11/06 30/06/06 7 YA35 18 30/08/06 8 YA42 23 30/06/06 Page 29 Version 5.1 9 YA42 23 10 YA43 25 required to supply copies of gas servicing appliances to the Commission. The registered manager is required to ensure that risk assessments for hot water outlets are reviewed and action recorded. The registered provider is required to ensure that accounts for service users monies are audited on an annual basis. 30/06/06 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA23 Good Practice Recommendations It is strongly recommended that staff commence POVA training within six months of employment. DS0000028414.V290165.R01.S.doc Version 5.1 Page 30 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. 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